Attention Assessment (Child)

1) Current Medications:

2) Rate your child's everyday stress level on a scale of 1-10 (1 is calm and 10 is completely out of control):
3) What would optimum performance look and feel like to you/your child?
4) What are the main symptoms you would like to track/significant factors?
5) Does your child currently have a medical/psychiatric diagnosis or are there any past diagnoses you think we should be aware of?
Please rate the following behaviors/skills on a scale of 1 thru 10, using all the numbers in between.

1 = Minor problem
2, 3, 4 = Problem - But I work around it
5 = Definitely a problem - Can't ignore but can live with it
6, 7, 8 = Big problem - Blocks who I want to be
9, 10 = Huge problem - Don't know what to do / overwhelmed / panic attacks

Please rate how often this happens:

	1	2	3	4	5	6	7	8	9	10
Understands/follows directions
Follows a sequence of 3 or more directions
Responds appropriately to 3 or more choices
Difficulty focusing and concentrating in school
Difficulty sitting still in his/her chair
Difficulty transitioning from one activity to another
Easily distracted
Impulsive behavior without thinking of consequences
Risky behaviors
Forgetful
Loses things
Easily overwhelmed
Feelings of impatience or restlessness
Difficulty completing assigned work
Organized in his/her work habits
Accident prone
Shouts out; can't wait to be called on
Cooperates/participates in group activities
Asks questions for clarity/understanding
Understands other person's emotions (happy, sad, angry)
Responds appropriately to other people's feelings
Makes friends of the same age
Overly sensitive to certain sounds
Insensitive to pain/heat/cold
Overreacts to pain
Unusual gait, such as tiptoe walking
Avoids touching certain textures such as food, clothing, stick things
Dislikes being touched
Enjoys rough and tumble play
Frustration or anger tantrums
Not easily calmed
Difficult to manage or discipline
Gets upset when daily routine changes
Difficulty getting to sleep at night
Difficulty staying asleep
Wakes up frequently during the night
Headaches
Seizures