Child's Name:_____________________________________________________
Completed on:_____________by: ______________________________________
Instructions: Please consider the last month only if filling out the checklist.
Check the appropriate column for each item, whichever best describes your assessment
of the child. Please complete all 10.
| Observation |
Degree of Activity |
| Not at All |
Just a Little |
Pretty Much |
Very Much |
|
1. Restless or overactive
|
0 |
1 |
2 |
3 |
|
2. Excitable, impulsive
|
0 |
1 |
2 |
3 |
|
3. Disturbs other children
|
0 |
1 |
2 |
3 |
|
4. Fails to finish things s/he starts, short attention span
|
0 |
1 |
2 |
3 |
|
5. Constantly fidgeting
|
0 |
1 |
2 |
3 |
|
6. Inattentive, easily distracted
|
0 |
1 |
2 |
3 |
|
7. Demands must be met immediately - easily frustrated
|
0 |
1 |
2 |
3 |
|
8. Cries often and easily
|
0 |
1 |
2 |
3 |
|
9. Mood changes quickly and drastically
|
0 |
1 |
2 |
3 |
|
10. Temper outbursts, explosive and unpredictable behavior
|
0 |
1 |
2 |
3 |
Less than 18 = Normal
18-21 = May be at risk
21+ = Consistent with ADHD
