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5
Questions
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HIPAA
Compliance
1
Patient Name
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
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-
Month
Day
Year
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3
Form Completed By:
Please give full name of person filling out this checklist.
First Name
Last Name
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4
Date
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5
Please select the option that best describes your child:
*
This field is required.
You must select one answer per row.
Never
Sometimes
Often
Fidgety, unhappy to sit still
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Feels sad, unhappy
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Daydreams too much
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Refuses to share
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Does not understand other people feelings
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Feels hopeless
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Has trouble concentrating
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Fights with other children
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Is down on him or her self
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Blames others for his or her troubles
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Seems to have less fun
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Does not listen to rules
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Acts as if driven by a motor
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Teases others
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Worries a lot
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Takes things that do not belong to him or her
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Distracted easily
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Fidgety, unhappy to sit still
Feels sad, unhappy
Daydreams too much
Refuses to share
Does not understand other people feelings
Feels hopeless
Has trouble concentrating
Fights with other children
Is down on him or her self
Blames others for his or her troubles
Seems to have less fun
Does not listen to rules
Acts as if driven by a motor
Teases others
Worries a lot
Takes things that do not belong to him or her
Distracted easily
Never
Row 0, Column 0
Sometimes
Row 0, Column 1
Often
Row 0, Column 2
Never
Row 1, Column 0
Sometimes
Row 1, Column 1
Often
Row 1, Column 2
Never
Row 2, Column 0
Sometimes
Row 2, Column 1
Often
Row 2, Column 2
Never
Row 3, Column 0
Sometimes
Row 3, Column 1
Often
Row 3, Column 2
Never
Row 4, Column 0
Sometimes
Row 4, Column 1
Often
Row 4, Column 2
Never
Row 5, Column 0
Sometimes
Row 5, Column 1
Often
Row 5, Column 2
Never
Row 6, Column 0
Sometimes
Row 6, Column 1
Often
Row 6, Column 2
Never
Row 7, Column 0
Sometimes
Row 7, Column 1
Often
Row 7, Column 2
Never
Row 8, Column 0
Sometimes
Row 8, Column 1
Often
Row 8, Column 2
Never
Row 9, Column 0
Sometimes
Row 9, Column 1
Often
Row 9, Column 2
Never
Row 10, Column 0
Sometimes
Row 10, Column 1
Often
Row 10, Column 2
Never
Row 11, Column 0
Sometimes
Row 11, Column 1
Often
Row 11, Column 2
Never
Row 12, Column 0
Sometimes
Row 12, Column 1
Often
Row 12, Column 2
Never
Row 13, Column 0
Sometimes
Row 13, Column 1
Often
Row 13, Column 2
Never
Row 14, Column 0
Sometimes
Row 14, Column 1
Often
Row 14, Column 2
Never
Row 15, Column 0
Sometimes
Row 15, Column 1
Often
Row 15, Column 2
Never
Row 16, Column 0
Sometimes
Row 16, Column 1
Often
Row 16, Column 2
1
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