D6 TEACHER FOLLOW UP

Teacher's Name *

Class Time

Class Name/Period

Today's Date *

Child's Name *

Grade Level *

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the last assessment scale was filled out.

Please indicate the number of weeks or months you have been able to evaluate the behaviors: *

Is this evaluation based on a time when the child *

Was on medication Was not on medication Not sure

Symptoms

	Never	Occasionally	Often	Very Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others’ conversations and/or activities

Performance

	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
19. Reading
20. Mathematics
21. Written expression
22. Relationship with peers
23. Following direction
24. Disrupting class
25. Assignment completion
26. Organizational skills

Side Effects: Has the child experienced any of the following side effects or problems in the past week?

	None	Mild	Moderate	Severe
Headache
Stomachache
Change of appetite—explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening—explain below
Socially withdrawn—decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Sees or hears things that aren’t there

Explain/Comments: