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BEHAVIORS |
Never |
Occas |
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 |
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(pencils, books, supplies) |
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 |
| |
|
|
|
|
|
| |
|
|
|
|
|
| 1 |
Fidgets with hands or feet or squirms in seat |
0 |
1 |
2 |
3 |
| 2 |
Leaves seat in classroom or in other situations in which remaining seated is expected |
0 |
1 |
2 |
3 |
| 3 |
Runs about or climbs excessively in situations in which remaining seated is expected |
0 |
1 |
2 |
3 |
| 4 |
Has difficulty playing or engaging in leisure activities quietly |
0 |
1 |
2 |
3 |
| 5 |
Is "on the go" or often acts as if "driven by a motor" |
0 |
1 |
2 |
3 |
| 6 |
Talks excessively |
0 |
1 |
2 |
3 |
| 7 |
Blurts out answers before questions have been completed |
0 |
1 |
2 |
3 |
|
8 |
Has difficulty waiting turns |
0 |
1 |
2 |
3 |
9 |
Interrupts or intrudes on others(i.e., butts into conversations or games) |
0 |
1 |
2 |
3 |
| |
|
|
|
|
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- Copy the above form and have it filled out by Mother, Father, Teacher/s and the Child(if over 8 - 9 yrs old)
- Only answers in the last 2 columns count--the often and very often columns.
How many positive marks in the last 2 columns of the top set of 9____________?
How many positive marks in the last 2 columns of the bottom set of 9_________?
Diagnosis of ADD: 6/9 or more positive in the top 9 statements
Diagnosis of ADHD: 6/9 or more positive in the bottom 9 statements
Diagnosis of the Combined Type: 6/9 or more positive in both sets of statements
NOTE: IN ADDITION TO THE ABOVE CRITERIA, THE FOLLOWING MUST ALSO BE TRUE:
1. The above behaviors must have started before age 7.
2. The behaviors must be present in 2 or more areas of the child's life, i.e. home, school, church, etc. Don't make the diagnosis if they are only noted at home.
3. The behaviors must cause significant impairment in functioning in either social, academic, or occupational areas. In other words, if the behaviors are present, but the child is doing fine at home, school, their personal life and/or work, then don't make the diagnosis.
4. The behaviors should have been present for at least 6 months.
5. If the child has some positive answers, but not enough to qualify for ADD/ADHD, it will be very important for your physician or other health care professional to help with the diagnosis.
This will give you a good idea if your child--or you--have ADD or ADHD, but it still needs interpretation by your Healthcare Professional.
Take the forms and your child to his physician to confirm your suspicions. The Doctor will need to examine the child and R/O other conditions which may have similar symptoms.
If you have any comments of ideas of things that would really help you, email me at:
DrJerry@ADHDStrategies.com
I want to help you "be the best person you can be"
Dr. Jerry Is Online
Jerry Rodgers, M.D.
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