CURRENT BEHAVIOR SCALE – PARENT REPORT

Child Name*

Child Birth Date*

MonthDayYear

Who is your Child's Provider?*

Who is filling out this form?

Instructions
Please circle the number next to each item that best describes the behaviour of your son or daughter when he or she was a child.

PLEASE RATE BEHAVIOUR AT AGE SEVEN (7 years of age)*

	Never or rarely	Sometimes	Often	Very Often
1. Failed to give close attention to details or made careless mistakes in work
2. Fidgeted with hands or feet or squirmed in seat
3. Had difficulty sustaining attention in tasks or fun activities
4. Left seat in classroom or other situations in which sitting was expected
5. Didn’t listen when spoken to directly
6. Restless in the “squirmy” sense
7. Didn’t follow through on instructions and failed to finish work
8. Had difficulty engaging in leisure activities or doing fun things quietly
9. Had difficulty organizing tasks and activities
10. Was “on the go all the time” or acted as if “driven by a motor”
11. Avoided, disliked, or was reluctant to engage in work that required sustained mental effort
12. Talked excessively
13. Lost things necessary for tasks or activities
14. Blurted out answers before questions had been completed
15. Easily distracted
16. Had difficulty awaiting turn
17. Forgetful in daily activities
18. Interrupted or intruded on others

To what extent did the problems you may have circled on the previous page interfere with their ability to function in each of these areas of life activities, when she or he was a child between 7 and 12 years of age?*

	Never or Rarely	Sometimes	Often	Very Often
In his/her home life with immediate family
In his/her social interactions with other children
In his/her activities or dealings in the community
In school
In sports, clubs, or other organizations
In learning to take care of themselves
In his/her play, leisure or recreational activities
In his/her handling of daily chores or other responsibilities

Date