Symptom

Never

Occasionally

Often

Very Often

1

Does not pay attention to details or makes careless mistakes with, for example, homework

0

1

2

3

2

Has difficulty keeping attention to what needs to be done.

0

1

2

3

3

Does not seem to listen when spoken to directly.

0

1

2

3

4

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

0

1

2

3

5

Has difficulty organizing tasks and activities

0

1

2

3

6

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

0

1

2

3

7

Loses things necessary for tasks or activities ( toys, assignments, pencils, or books)

0

1

2

3

8

Is easily distracted by noises or other stimuli

0

1

2

3

9

Is forgetful in daily activities

0

1

2

3

10

Fidgets with hands or feet or squirms in seat

0

1

2

3

11

Leaves seat when remaining seated is expected

0

1

2

3

12

Runs about and climbs too much when remaining seated is expected

0

1

2

3

13

Has difficulty playing or beginning quiet play activities

0

1

2

3

14

Is "on the go" or often acts if  "driven by motor"

0

1

2

3

15

Talks too much

0

1

2

3

16

Blurts out answers before questions have been completed

0

1

2

3

17

Has difficulty waiting his or her turn

0

1

2

3

18

Interrupts or intrudes in others' conversations and/ or activities

0

1

2

3

19

Argues with adults

0

1

2

3

20

Loses temper

0

1

2

3

21

Actively defies or refuses to go along with adults' request or rules

0

1

2

3

22

Deliberately annoys people

0

1

2

3

23

Blames others for his or her mistakes or misbehaviors

0

1

2

3

24

Is touchy or easily annoyed by others

0

1

2

3

25

Is angry or resentful

0

1

2

3

26

Is spiteful and wants to get even

0

1

2

3

27

Bullies, threatens, or intimidates other

0

1

2

3

28

Starts physical fights

0

1

2

3

29

Lies to get out of trouble or the avoid obligations (ie, "cons" others)

0

1

2

3

30

Is truant from school ( skips school) without permission

0

1

2

3

31

Is physical cruel to people

0

1

2

3

32

Has stolen things that have value

0

1

2

3

33

Deliberately destroys others' property

0

1

2

3

34

Has used a weapon that can cause serious harm ( bat, knife, brick, gun)

0

1

2

3

35

Is physically cruel to animals

0

1

2

3

36

Has deliberately set fires to cause damage

0

1

2

3

37

Has broken into someone else's home, business, or car

0

1

2

3

38

Has stayed out at night without permission

0

1

2

3

39

Has run away from home overnight

0

1

2

3

40

Has forced someone into sexual activity

0

1

2

3

41

Is fearful, anxious , or worried

0

1

2

3

42

Is afraid to try new things for fear of making mistakes

0

1

2

3

43

Feels worthless or inferior

0

1

2

3

44

Blames self for problems, feels guilty

0

1

2

3

45

Feels lonely, unwanted, or unloved; complains that "no one loves him or her"

0

1

2

3

46

Is sad, unhappy, or depressed

0

1

2

3

47

Is self-conscious or easily embarrassed

0

1

2

3

Performance

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

48

Overall school performance

1

2

3

4

5

49

Reading

1

2

3

4

5

50

Writing

1

2

3

4

5

51

Mathematics

1

2

3

4

5

52

Relationship with parents

1

2

3

4

5

53

Relationship with siblings

1

2

3

4

5

54

Relationship with peers

1

2

3

4

5

55

Participation in organized activities (eg, teams)

1

2

3

4

5