ADHD Evaluation
On a scale of 1 to 10, with 10 being the most, please answer the following questions:
Is your child fidgety
No
1
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4
5
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7
8
9
Totally
10
1 is No, 10 is Totally
Is your child impulsive?
No
1
2
3
4
5
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7
8
9
Totally
10
1 is No, 10 is Totally
Is your child easily distracted?
No
1
2
3
4
5
6
7
8
9
Totally
10
1 is No, 10 is Totally
Does he or she act up in class?
No
1
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3
4
5
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7
8
9
Totally
10
1 is No, 10 is Totally
Do the teachers send home notes?
No
1
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3
4
5
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7
8
9
Totally
10
1 is No, 10 is Totally
Does he/she complete assignments?
Yes
1
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8
9
Never
10
1 is Yes, 10 is Never
Are you always repeating yourself?
No
1
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7
8
9
Totally
10
1 is No, 10 is Totally
Does he/she always interrupt you?
No
1
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7
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9
Totally
10
1 is No, 10 is Totally
Is he/she forgetful at home?
No
1
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3
4
5
6
7
8
9
Totally
10
1 is No, 10 is Totally
Signature and Date
Clear
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