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    ADHD Checklist PDF

    Uploaded by

    Carlo Precioso
    This document appears to be an ADHD checklist from a physician assessing a patient's symptoms. It includes sections to check boxes rating the patient's attention issues, hyperactivity/impulsivity, and oppositional defiant disorder symptoms both currently and retrospectively in childhood. It also has space for current medications, diagnoses, and physician comments.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ADHD Checklist PDF

    Uploaded by

    Carlo Precioso
    350 views1 page
    This document appears to be an ADHD checklist from a physician assessing a patient's symptoms. It includes sections to check boxes rating the patient's attention issues, hyperactivity/impulsivity, and oppositional defiant disorder symptoms both currently and retrospectively in childhood. It also has space for current medications, diagnoses, and physician comments.

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    ADHD Checklist.pdf

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    This document appears to be an ADHD checklist from a physician assessing a patient's symptoms. It includes sections to check boxes rating the patient's attention issues, hyperactivity/impulsivity, and oppositional defiant disorder symptoms both currently and retrospectively in childhood. It also has space for current medications, diagnoses, and physician comments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    350 views1 page

    ADHD Checklist PDF

    Uploaded by

    Carlo Precioso
    This document appears to be an ADHD checklist from a physician assessing a patient's symptoms. It includes sections to check boxes rating the patient's attention issues, hyperactivity/impulsivity, and oppositional defiant disorder symptoms both currently and retrospectively in childhood. It also has space for current medications, diagnoses, and physician comments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Patient Name:

    Date of Birth: MRN/File No:


    Physician Name: Date:

    Retrospective assessment of childhood symptoms Current symptoms


    ADHD CHECKLIST Current medication:

    SYMPTOMS: Check the appropriate box Not at all Somewhat Pretty much Very much Diagnoses
    (0) (1) (2) (3)

    ATTENTION 314.00 (≥6/9) SEVERITY TOTAL


    Fails to give close attention to details, careless mistakes

    Difficulty sustaining attention in tasks or fun activities

    Does not seem to listen when spoken to directly

    Does not follow through on instructions and fails to finish work

    Difficulty organizing tasks and activities

    Avoids tasks that require sustained mental effort (boring)

    Losing things


    Easily distracted _/9


    Forgetful in daily activities ≥6/9

    HYPERACTIVE/IMPULSIVE 314.01 (≥6/9)


    Fidgety or squirms in seat

    Leaves seat when sitting is expected

    Feels restless

    Difficulty in doing fun things quietly

    Always on the go or acts as if "driven by a motor"

    Talks excessively

    Blurts answers before questions have been completed


    Difficulty awaiting turn ≥6/9


    Interrupting or intruding on others _/9

    OPPOSITIONAL DEFIANT DISORDER 313.81 (>4/8)


    Loses temper

    Argues with adults

    Actively defies or refuses to comply with requests or rules

    Deliberately annoys people

    Blames others for his or her mistakes or misbehavior

    Touchy or easily annoyed by others


    Angry or resentful ≥4/8


    Spiteful or vindictive _/8

    COMMENTS

    8.20 Version: March 2014. Refer to www.caddra.ca for latest updates.

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