Johansen Checklist

Client's Name:

First NameLast Name

Client's Age:

Date

Parent Name (completing form):

First NameLast Name

Email:

example@example.com

Please select one of the answers for each question and, if necessary, add brief examples in the comments field.

ATTENTION:

A1. Does your child fidget with his/her hands or feet or squirm in his/her seat? (in adolescents this may be limited to subjective feelings of restlessness)

Comments:

A2. Does your child have difficulty remaining in his/her seat when required to do so?

Comments:

A3. Does your child have difficulty awaiting his/her turn in games or group situations?

Comments:

A4. Does your child blurt out answers to questions before they have been completed?

Comments:

A5. Does your child have difficulty following through with instructions from others, or fail to finish chores (not due to oppositional behavior or failure to comprehend)?

Comments:

A6. Does your child have difficulty sustaining attention to tasks or activities?

Comments:

A7. Does your child shift from one uncompleted activity to another?

Comments:

A8. Does your child have difficulty playing quietly?

Comments:

A9. Does your child talk excessively?

Comments:

A10. Does your child interrupt or intrude on others (e.g. butts into other's games)?

Comments:

A11. Does your child seem not to listen to what is being said to him/her?

Comments:

A12. Does your child lose things necessary for tasks or activities at school or at home? (toys, pencils, books, homework, clothes)

Comments:

A13. Does your child engage in physically dangerous activities without considering the possible consequences? (not thrill-seeking, e.g. runs into the street without looking)

Comments:

BEHAVIOR:

B1. Does your child lose his/her temper?

Comments:

B2. Does your child argue with adults?

Comments:

B3. Does your child actively defy adults, refuse requests or break rules?

Comments:

B4. Does your child deliberately do things to annoy other people?

Comments:

B5. Does your child blame others for his/her mistakes?

Comments:

B6. Is your child touchy or easily annoyed?

Comments:

B7. Is your child angry or resentful?

Comments:

B8. Is your child spiteful or vindictive?

Comments:

B9. Does your child show marked distress over changes in routine or environment?

Comments:

B10. Does your child lack interest in imaginative activities (e.g. playing a role in a game, or in stories about imaginary events)?

Comments:

B11. Does your child have difficulty making friends his/her own age?

Comments:

B12. Does your child have difficulty getting to sleep or sleeping through the night?

Comments:

B13. Does your child have nightmares?

Comments:

B14. Is your child reluctant to go to school?

Comments:

B15. Is your child distressed when separated from home?

Comments:

COORDINATION:

C1. Does your child have difficulty dressing (buttons, laces, tie, etc.)?

Comments:

C2. Does your child have difficulty with ball games (kicking, tennis, etc.)?

Comments:

C3. Does your child find it hard to do physical activities such as cartwheels?

Comments:

C4. Does your child bump into things and people?

Comments:

C5. Is your child having difficulty forming letters for printing or cursive?

Comments:

C6. Does your child suffer from travel sickness?

Comments:

C7. Does your child wet the bed?

Comments:

C8. Does your child have trouble with left/right when giving/receiving directions?

Comments:

LANGUAGE:

L1. Does your child find it difficult to pronounce some sounds in words correctly?

Comments:

L2. Does your child find it difficult to say long words correctly?

Comments:

L3. Does your child find it difficult to learn new words (i.e. to broaden his/her spoken vocabulary)?

Comments:

L4. Does your child find it difficult to find the words he/she wants to say?

Comments:

L5. Does your child find it difficult to construct sentences accurately when speaking?

Comments:

L6. Does your child find it difficult to ask questions (not through shyness)?

Comments:

L7. Does your child have difficulty initiating or carrying on a conversation with others?

Comments:

L8. Does your child lack confidence in speaking?

Comments:

L9. Does your child find it hard to look at the person they are speaking or listening to?

Comments:

L10. Does your child lack self-confidence in situations other than speaking?

Comments:

L11. Does your child have difficulty with reading?

Comments:

L12. Does your child have difficulty spelling words correctly?

Comments:

L13. Does your child find it difficult to write down his/her thoughts on paper when they know what they want to say?

Comments: