Info
Parent Name                                                   First      Last
 
Child  Name                                                    First Last  
 
Child Birthday (mm/dd/yy)      
Zipcode      
 
Parent email
Address
    
Part I
Home School Community
1. Does your child fail to give attention to details?
2. Is it difficult for your child to sustain attention?
3. Does your child seem not listen?
4. Does your child fail to follow through on instructions?
5. Does your child have difficulty organizing tasks or activities?
6. Does your child avoid, dislike, or is reluctant to engage in tasks requiring sustained mental effort?
7. Does your child lose things necessary for tasks or activities?
8. Is your child easily distracted by extraneous stimuli?
9. Is your child forgetful in daily activies?
Part II
Home School Community
1. Does your child fidget with hands or feet or squirms in his seat?
2. Does your child leave his seat inappropriately?
3. Does your child run about or climb excessively?
4. Does your child have difficulty playing or engaging in leisure activities quietly?
5. Is your child "on the go" or acts as if "driven by a motor" ?
6. Does your child blurt out answers before the question is completed?
7. Does your child have difficulty waiting his turn?
8. Does your child talk excessively?
9. Does your child interrupt or intrude on others?

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