Symptom

Never

Occasionally

Often

Very Often

1

Fails to give attention to details, or makes careless mistakes in schoolwork

0

1

2

3

2

Has difficulty sustaining attention to tasks or activities

0

1

2

3

3

Does not seem to listen when spoken to directly

0

1

2

3

4

Does not follow through on instructions, and fails to finish schoolwork (not due to oppositional behavior or failure to understand)

0

1

2

3

5

Has difficulty organizing tasks and activities

0

1

2

3

6

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

0

1

2

3

7

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

0

1

2

3

8

Is easily distracted by extraneous 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 in classroom or in other situations in which remaining seated is expected

0

1

2

3

12

Runs about or climbs excessively in situations in which remaining seated is expected

0

1

2

3

13

Has difficulty playing or engaging in leisure activities quietly

0

1

2

3

14

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

0

1

2

3

15

Talks excessively

0

1

2

3

16

Blurts out answers before questions have been completed

0

1

2

3

17

Has difficulty waiting in line

0

1

2

3

18

Interrupts or intrudes on others (eg, butts into conversations/games)

0

1

2

3

19

Loses temper

0

1

2

3

20

Actively defies or refuses to comply with adults' requests or rules

0

1

2

3

21

Is angry or resentful

0

1

2

3

22

Is spiteful and vindictive

0

1

2

3

23

Bullies, threatens, or intimidates others

0

1

2

3

24

Initiates physical fights

0

1

2

3

25

Lies to obtain goods for favors, or to avoid obligations ("cons" others)

0

1

2

3

26

Is physically cruel to people

0

1

2

3

27

Has stolen items of nontrivial value

0

1

2

3

28

Deliberately destroys others' property

0

1

2

3

29

Is fearful, anxious, or worried

0

1

2

3

30

Is self-conscious or easily embarrassed

0

1

2

3

31

Is afraid to try new things for fear of making mistakes

0

1

2

3

32

Feels worthless or inferior

0

1

2

3

33

Blames self for problems; feels guilty

0

1

2

3

34

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

0

1

2

3

35

Is sad, unhappy, or depressed

0

1

2

3

Academic Performance

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

36

Reading

1

2

3

4

5

37

Mathematics

1

2

3

4

5

38

Written expression

1

2

3

4

5

Classroom Behavior

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

39

Relationship with peers

1

2

3

4

5

40

Following directions

1

2

3

4

5

41

Disrupting class

1

2

3

4

5

42

Assignment completion

1

2

3

4

5

43

Organizational skills

1

2

3

4

5