Student’s name:
Date :
This questionnaire helps to assess common problem areas seen in the classroom. It is possible that the student's problems are not related to one of these areas.
For item 1, circle the number in the column which best describes behaviors you observe.
3 = "Very much" (one or more times each day)
2 = "Pretty much" (several time a week)
1 = “Just a little” ( less than 4 to 8 times a month).
Both 2 and 3 indicate a marked to serious problem, which is interfering with this student’s academic success, social interactions, and/or emotional issues.
1 2 3 4
1. Attention, Activity Level, and Related Behaviors
all little much much.
2. Fails to give close attention to details or makes careless
2. Fails to give close attention to details or makes careless
mistakes in school work or other activities.
3. Difficulty sustaining attention in tasks or play activities.
4. Does not seem to listen when spoken to directly.
5. Does not follow through on instructions &
3. Difficulty sustaining attention in tasks or play activities.
4. Does not seem to listen when spoken to directly.
5. Does not follow through on instructions &
fails to finish schoolwork, chores, etc.
6. Difficulty organizing tasks and activities.
7. Avoids, dislikes, or is reluctant to engage in tasks
7. Avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort .
(such as school work or homework).
8. Loses things necessary for tasks or activities
8. Loses things necessary for tasks or activities
(e.g. school supplies, toys).
9. Easily distracted by extraneous stimuli, such as
9. Easily distracted by extraneous stimuli, such as
other things happening.
10. Forgetful in daily activities.
11. Fidgets with hands or feet or squirms in seat.
12. Leaves seat in classroom or in other situations
10. Forgetful in daily activities.
11. Fidgets with hands or feet or squirms in seat.
12. Leaves seat in classroom or in other situations
when unexpected to do so.
13. Runs about/climbs excessively in situations where
13. Runs about/climbs excessively in situations where
it is inappropriate.
14. Difficulty in playing or engaging in leisure activities quietly.
15. "On the go" or acts as if "driven by a motor".
16. Talks excessively.
17. Blurts out answers before questions have been completed.
18. Difficulty waiting his or her turn.
19. Interrupts or intrudes on others
14. Difficulty in playing or engaging in leisure activities quietly.
15. "On the go" or acts as if "driven by a motor".
16. Talks excessively.
17. Blurts out answers before questions have been completed.
18. Difficulty waiting his or her turn.
19. Interrupts or intrudes on others
(butts into conversations/games).
To determine if the child encounter visual problem:
20. Loses place while reading
21. Avoids close work
22. Tends to rub eyes
23.Has headaches
24.Turns or tilts head
25.Makes frequent reversals when reading or writing
26.Uses finger to maintain place when reading
27. Omits or confuses small words when reading
28. Consistently performs below potential
28. Struggles to complete homework
29. Squints while reading or watching television
30.Has behavioral problems
31. Holds reading material closer than normal
How long have the 2s and 3s in A.1-A.9 been present? ________________
Comments?:
21. Avoids close work
22. Tends to rub eyes
23.Has headaches
24.Turns or tilts head
25.Makes frequent reversals when reading or writing
26.Uses finger to maintain place when reading
27. Omits or confuses small words when reading
28. Consistently performs below potential
28. Struggles to complete homework
29. Squints while reading or watching television
30.Has behavioral problems
31. Holds reading material closer than normal
How long have the 2s and 3s in A.1-A.9 been present? ________________
Comments?:
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