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    ADHD Evaluation Form: Parent and Teacher Version (Assessment)

    Uploaded by

    Jack Tedesco
    This form is used to help health care providers diagnose ADHD. It contains questions about inattention and hyperactivity/impulsivity for parents and teachers to rate on a scale of none/some/quite often/very often. It also asks if behaviors are clearly more than other children the same age. Responses help identify symptoms and determine if they are more severe than typical for a child's age. The form should be completed and returned to the health care provider to aid in their ADHD evaluation and diagnosis.

    Copyright:

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

    ADHD Evaluation Form: Parent and Teacher Version (Assessment)

    Uploaded by

    Jack Tedesco
    119 views3 pages
    This form is used to help health care providers diagnose ADHD. It contains questions about inattention and hyperactivity/impulsivity for parents and teachers to rate on a scale of none/some/quite often/very often. It also asks if behaviors are clearly more than other children the same age. Responses help identify symptoms and determine if they are more severe than typical for a child's age. The form should be completed and returned to the health care provider to aid in their ADHD evaluation and diagnosis.

    Original Title

    ADHD Evaluation-Tool

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    © © All Rights Reserved

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    This form is used to help health care providers diagnose ADHD. It contains questions about inattention and hyperactivity/impulsivity for parents and teachers to rate on a scale of none/some/quite often/very often. It also asks if behaviors are clearly more than other children the same age. Responses help identify symptoms and determine if they are more severe than typical for a child's age. The form should be completed and returned to the health care provider to aid in their ADHD evaluation and diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    119 views3 pages

    ADHD Evaluation Form: Parent and Teacher Version (Assessment)

    Uploaded by

    Jack Tedesco
    This form is used to help health care providers diagnose ADHD. It contains questions about inattention and hyperactivity/impulsivity for parents and teachers to rate on a scale of none/some/quite often/very often. It also asks if behaviors are clearly more than other children the same age. Responses help identify symptoms and determine if they are more severe than typical for a child's age. The form should be completed and returned to the health care provider to aid in their ADHD evaluation and diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    ADHD 

    Evaluation Form: Parent and Teacher Version (Assessment) 
    This form can be used as an aid to help a health care provider in the diagnosis of Attention Deficit 
    Hyperactivity Disorder.  Please complete the form as instructed by the health care provider. 
     
    First, put a check mark in box number 1, 2 or 3 that best describes the young person as they USUALLY 
    are.  Then, once you have done that, if the score is 3 (very often box) please decide if, in your opinion, 
    the young person shows that characteristic “Clearly more than other young people at this age”.    Thus, 
    some items may have two check marks in their rows and some items may have only one. 
     
    Note not all young people who demonstrate symptoms of ADHD have ADHD. 
     
      (1)  (2)  (3)  (4) 
      None or  Quite  Very  Clearly more than other 
    Inattention item  Some  often  Often  young people at this 
    age 
    a.  Often fails to give close attention to details or         
    makes careless mistakes in schoolwork, at work , or 
    during other activities (e.g., overlooks or misses 
    details, work is inaccurate) 
    b. Often has difficulty sustaining attention in tasks         
    or play activities (e.g., has difficulty remaining 
    focused during lectures, conversations, or lengthy 
    reading) 
    c. Often does not seem to listen when spoken to         
    directly (e.g., mind seems elsewhere, even in the 
    absence of any obvious distraction) 
    d. Often does not follow through on instructions         
    and falls to finish schoolwork, chores, or duties in 
    the workplace (e.g., starts tasks but quickly loses 
    focus and is easily sidetracked) 
    e. Often has difficulty organizing tasks and         
    activities (e.g., difficulty managing sequential tasks; 
    difficulty keeping materials and belongings in 
    order; messy, disorganized work; has poor time 
    management; fails to meet deadlines) 
    f. Often avoids, dislikes, or is reluctant to engage in         
    tasks that require sustained mental effort (e.g., 
    schoolwork or homework; for older adolescents 
    and adults, preparing reports, completing reports, 
    reviewing lengthy papers) 
    g. Often loses things necessary for tasks or         
    activities (e.g., school materials, pencils, books, 
    tools, wallets, keys, paperwork, eyeglasses, mobile 
    telephones) 
    h. Is often easily distracted by extraneous stimuli         
    (for older adolescents and adults, may include 
    unrelated thoughts) 
    i. Is often forgetful in daily activities (e.g., doing         
    chores, running errands; for older adolescents and 
    adults, returning calls, paying bills, keeping 
    appointments) 
    TOTALS        
     
     
     
      (1)  (2)  (3)  (4) 
    Hyperactivity/Impulsivity items  None or  Quite  Very  Clearly more than 
    Some  often  Often  other young people 
    this age 
    a. Often fidgets with or taps hands or feet or         
    squirms in seat 
    b. Often leaves seat in situations when reaming         
    seated is expected (e.g., leaves his or her place in 
    the classroom, in the office or other workplace, or 
    in other situations that require remaining in place) 
    c. Often runs about or climbs in situations where it         
    is inappropriate. (Note: In adolescents or adults, 
    may be limited to feeling restless) 
    d. Often unable to play or engage in leisure         
    activities quietly  
    e. Is often “on the go,” acting as if “driven by a         
    motor” (e.g., is unable to be or uncomfortable 
    being still for extended time, as in restaurants, 
    meetings; may be experienced by others as being 
    restless or difficult to keep up with) 
    f. Often talks excessively         
    g. Often blurts out an answer before a question has         
    been completed (e.g., completes people’s 
    sentences; cannot wait for turn in conversation) 
    h. Often has difficulty waiting his or her turn (e.g.,         
    while waiting in line) 
    i. Often interrupts or intrudes on others (e.g., butts         
    into conversations, games, or activities; may start 
    using other people’s things without asking or 
    receiving permission; for adolescents and adults, 
    may intrude into or take over what others are 
    doing) 
    TOTALS        
     
    Thank you for filling out this form.  Please return it to your health care 
    provider. 
     
     
     
     
     

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