Attention Deficit Disorder Evaluation Form

1. Fail to pay close attention to details, or makes careless mistakes in schoolwork, work or other activities Not at all Just a Little Pretty Much Very Much

2. Difficulty sustaining attention in tasks or play activities Not at all Just a Little Pretty Much Very Much

3. Not seeming to listen to what is being said Not at all Just a Little Pretty Much Very Much

4. Not follow through on instructions and fail to finish chores, schoolwork, or duties at work (not due to oppositionality or failure to understand instructions) Not at all Just a Little Pretty Much Very Much

5. Difficulty organizing tasks and activities Not at all Just a Little Pretty Much Very Much

6. Avoid or strongly dislike tasks (such as schoolwork or homework) that require sustained mental effort Not at all Just a Little Pretty Much Very Much

7. Lose things necessary for tasks or activities (e.g. school assignments, toys, books, pencils, tools) Not at all Just a Little Pretty Much Very Much

8. Easily distracted by extraneous stimuli Not at all Just a Little Pretty Much Very Much

9. Forgetful in daily activities Not at all Just a Little Pretty Much Very Much

1. Fidget with hands/feet or squirm in seat Not at all Just a Little Pretty Much Very Much

2. Leave seat in classroom, or in other situations where remaining seated is expected Not at all Just a Little Pretty Much Very Much

3. Run about or climb excessively in situations where it is inappropriate (in adults, may be limited to subjective feelings of restlessness) Not at all Just a Little Pretty Much Very Much

4. Difficulty playing or engaging in leisure activities quietly Not at all Just a Little Pretty Much Very Much

5. Always “on the go” or act as if “driven by a motor” Not at all Just a Little Pretty Much Very Much

6. Talk excessively Not at all Just a Little Pretty Much Very Much

7. Blurt out answers to questions before questions have been completed Not at all Just a Little Pretty Much Very Much

8. Difficulty waiting in lines, or waiting turn in games or groups Not at all Just a Little Pretty Much Very Much

9. Interrupt or intrude on others (e.g. butt into other’s games, activities, or conversations) Not at all Just a Little Pretty Much Very Much