Academic Questionnaire

1
Student Info* This field is required.
First Name
Last Name
Email
2
Reading* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
1. I am a poor reader.
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2. I do not like reading.
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3. I make mistakes when reading like skipping words or lines.
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4. I read the same line twice
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5. I have problems remembering what I read even though I have read all the words.
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6. I reverse letters when I read (such as b/d, p/q).
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7. I switch letters in words when reading (such as god and dog).
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8. I complain that my eyes hurt or water when I read.
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9. Words tend to blur when I read.
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10. Words tend to move around the page when I read.
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11. When reading I have difficulty understanding the main idea or identifying
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1. I am a poor reader.
2. I do not like reading.
3. I make mistakes when reading like skipping words or lines.
4. I read the same line twice
5. I have problems remembering what I read even though I have read all the words.
6. I reverse letters when I read (such as b/d, p/q).
7. I switch letters in words when reading (such as god and dog).
8. I complain that my eyes hurt or water when I read.
9. Words tend to blur when I read.
10. Words tend to move around the page when I read.
11. When reading I have difficulty understanding the main idea or identifying
0
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1
Row 0, Column 1
2
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3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
0
Row 6, Column 0
1
Row 6, Column 1
2
Row 6, Column 2
3
Row 6, Column 3
4
Row 6, Column 4
NA
Row 6, Column 5
0
Row 7, Column 0
1
Row 7, Column 1
2
Row 7, Column 2
3
Row 7, Column 3
4
Row 7, Column 4
NA
Row 7, Column 5
0
Row 8, Column 0
1
Row 8, Column 1
2
Row 8, Column 2
3
Row 8, Column 3
4
Row 8, Column 4
NA
Row 8, Column 5
0
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1
Row 9, Column 1
2
Row 9, Column 2
3
Row 9, Column 3
4
Row 9, Column 4
NA
Row 9, Column 5
0
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1
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2
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3
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4
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NA
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3
Writing* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
12. I have “messy “ handwriting.
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13. My work tends to be messy.
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14. I prefer print rather than writing in cursive.
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15. My letters run into each other or there is no space between words.
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16. I have trouble staying within lines.
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17. I have problems with grammar or punctuation.
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18. I am a poor speller.
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19. I have trouble copying off the board or from a page in a book.
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20. I have trouble getting thoughts from my brain to the paper.
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21. I can tell a story but cannot write it.
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12. I have “messy “ handwriting.
13. My work tends to be messy.
14. I prefer print rather than writing in cursive.
15. My letters run into each other or there is no space between words.
16. I have trouble staying within lines.
17. I have problems with grammar or punctuation.
18. I am a poor speller.
19. I have trouble copying off the board or from a page in a book.
20. I have trouble getting thoughts from my brain to the paper.
21. I can tell a story but cannot write it.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
0
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1
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2
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3
Row 6, Column 3
4
Row 6, Column 4
NA
Row 6, Column 5
0
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1
Row 7, Column 1
2
Row 7, Column 2
3
Row 7, Column 3
4
Row 7, Column 4
NA
Row 7, Column 5
0
Row 8, Column 0
1
Row 8, Column 1
2
Row 8, Column 2
3
Row 8, Column 3
4
Row 8, Column 4
NA
Row 8, Column 5
0
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1
Row 9, Column 1
2
Row 9, Column 2
3
Row 9, Column 3
4
Row 9, Column 4
NA
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4
Body Awareness/ Spatial Relationships* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
22. I have trouble with knowing my left from my right.
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23. I have trouble keeping things within columns or coloring within lines.
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24. I tend to be clumsy, uncoordinated.
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25. I have difficulty with eye hand coordination.
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26. I have difficulty with concepts such as up, down, over or under.
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27. I tend to bump into things when walking.
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22. I have trouble with knowing my left from my right.
23. I have trouble keeping things within columns or coloring within lines.
24. I tend to be clumsy, uncoordinated.
25. I have difficulty with eye hand coordination.
26. I have difficulty with concepts such as up, down, over or under.
27. I tend to bump into things when walking.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
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2
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3
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4
Row 4, Column 4
NA
Row 4, Column 5
0
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1
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NA
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5
Oral Expressive language* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
28. I have difficulty expressing myself in words.
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29. I have trouble finding the right word to say in conversations.
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30. I have trouble talking around a subject or getting to the point in conversations.
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28. I have difficulty expressing myself in words.
29. I have trouble finding the right word to say in conversations.
30. I have trouble talking around a subject or getting to the point in conversations.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
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2
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3
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4
Row 1, Column 4
NA
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0
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1
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2
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4
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NA
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6
Receptive language* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
31. I have trouble keeping up or understanding what is being said in conversations.
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32. I tend to misunderstand people and give the wrong answers in conversations.
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33. I have trouble understanding directions people tell me.
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34. I have trouble telling the direction sound is coming from.
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35. I have trouble filtering out background noises.
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31. I have trouble keeping up or understanding what is being said in conversations.
32. I tend to misunderstand people and give the wrong answers in conversations.
33. I have trouble understanding directions people tell me.
34. I have trouble telling the direction sound is coming from.
35. I have trouble filtering out background noises.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
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3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
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2
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3
Row 4, Column 3
4
Row 4, Column 4
NA
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7
Math* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
36. I am poor at basic math skills for my age (adding, subtracting, multiplying and dividing)
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37. I makes “careless mistakes” in math.
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38. I tend to switch numbers around.
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39. I have difficulty with word problems.
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36. I am poor at basic math skills for my age (adding, subtracting, multiplying and dividing)
37. I makes “careless mistakes” in math.
38. I tend to switch numbers around.
39. I have difficulty with word problems.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
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3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
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3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
1 of 4
8
Sequencing* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
40. I have trouble getting everything in the right order when I speak.
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41. I have trouble telling time.
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42. I have trouble using the alphabet in order.
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43. I have trouble saying the months of the year in order.
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40. I have trouble getting everything in the right order when I speak.
41. I have trouble telling time.
42. I have trouble using the alphabet in order.
43. I have trouble saying the months of the year in order.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
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9
Abstraction* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
44. I have trouble understanding jokes people tell me.
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45. I tend to take things too literally.
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44. I have trouble understanding jokes people tell me.
45. I tend to take things too literally.
0
Row 0, Column 0
1
Row 0, Column 1
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Row 0, Column 2
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Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
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3
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4
Row 1, Column 4
NA
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10
Organization* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
46. My notebook/paperwork is messy or disorganized.
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47. My room is messy.
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48. I tend to shove everything into my backpack, desk or closet.
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49. I have multiple piles around my room.
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50. I have trouble planning my time.
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51. I am frequently late or in a hurry.
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52. I often do not write down assignments or tasks and end up forgetting what to do.
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46. My notebook/paperwork is messy or disorganized.
47. My room is messy.
48. I tend to shove everything into my backpack, desk or closet.
49. I have multiple piles around my room.
50. I have trouble planning my time.
51. I am frequently late or in a hurry.
52. I often do not write down assignments or tasks and end up forgetting what to do.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
0
Row 6, Column 0
1
Row 6, Column 1
2
Row 6, Column 2
3
Row 6, Column 3
4
Row 6, Column 4
NA
Row 6, Column 5
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11
Memory* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
53. I have trouble with my memory.
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54. I remember things from long ago but not recent events.
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55. It is hard for me to memorize things for school or work.
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56. I know something one day but do not remember it to the next.
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57. I forget what I am going to say right in the middle of saying it.
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58. I have trouble following directions that have more than one or two steps.
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53. I have trouble with my memory.
54. I remember things from long ago but not recent events.
55. It is hard for me to memorize things for school or work.
56. I know something one day but do not remember it to the next.
57. I forget what I am going to say right in the middle of saying it.
58. I have trouble following directions that have more than one or two steps.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
1 of 6
12
Social Skills * This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
59. I have few or no friends.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
60. I have trouble reading body language or facial expressions of others.
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
61. My feelings are often or easily hurt.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
62. I tend to get into trouble with friends, teachers, parents or bosses.
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
63. I feel uncomfortable around people I do not know well.
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
64. I am teased by others.
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
65. Friends do not call and ask me to do things with them.
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
66. I do not get together with others outside of school or work.
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
59. I have few or no friends.
60. I have trouble reading body language or facial expressions of others.
61. My feelings are often or easily hurt.
62. I tend to get into trouble with friends, teachers, parents or bosses.
63. I feel uncomfortable around people I do not know well.
64. I am teased by others.
65. Friends do not call and ask me to do things with them.
66. I do not get together with others outside of school or work.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
0
Row 6, Column 0
1
Row 6, Column 1
2
Row 6, Column 2
3
Row 6, Column 3
4
Row 6, Column 4
NA
Row 6, Column 5
0
Row 7, Column 0
1
Row 7, Column 1
2
Row 7, Column 2
3
Row 7, Column 3
4
Row 7, Column 4
NA
Row 7, Column 5
1 of 8
13
Scotopic Sensitivity * This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
67. I am light sensitive. Bothered by glare, sunlight, headlights or streetlights.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
68. I become tired, experience headaches, mood changes, feel restless or an inability to stay focused with bright or fluorescent lights.
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
69. I have trouble reading words that are on white, glossy paper.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
70. When reading words or letters shift, shake, blur, move, run together, disappear or become difficult to perceive.
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
71. I feel tense, tired, sleepy, or even get headaches with reading.
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
72. I have problems judging distance and have difficulty with such things as stairs, ball sports, or driving.
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
67. I am light sensitive. Bothered by glare, sunlight, headlights or streetlights.
68. I become tired, experience headaches, mood changes, feel restless or an inability to stay focused with bright or fluorescent lights.
69. I have trouble reading words that are on white, glossy paper.
70. When reading words or letters shift, shake, blur, move, run together, disappear or become difficult to perceive.
71. I feel tense, tired, sleepy, or even get headaches with reading.
72. I have problems judging distance and have difficulty with such things as stairs, ball sports, or driving.
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
1 of 6
14
Attention, Executive Function, and Hyperactivity* This field is required.0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
0
1
2
3
4
NA
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Often has difficulty sustaining attention in tasks or play activities
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Often does not seem to listen when spoken to directly
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Often has difficulty organizing tasks and activities
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Is often easily distracted by extraneous stimuli
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Is often forgetful in daily activities
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Often fidgets with hands or feet or squirms in seat
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Often leaves seat in classroom or in other situations in which remaining seated is expected
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Row 11, Column 5
Often has difficulty playing or engaging in leisure activities quietly
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Row 12, Column 5
Is often "on the go" or often acts as if "driven by a motor"
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Row 13, Column 5
Often talks excessively
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Row 14, Column 5
Often blurts out answers before questions have been completed
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Row 15, Column 5
Often has difficulty waiting turn
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Row 16, Column 5
Often interrupts or intrudes on others (e.g., butts into conversations or games)
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Row 17, Column 5
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
Often has difficulty organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
Often has difficulty playing or engaging in leisure activities quietly
Is often "on the go" or often acts as if "driven by a motor"
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty waiting turn
Often interrupts or intrudes on others (e.g., butts into conversations or games)
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
NA
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
NA
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
NA
Row 2, Column 5
0
Row 3, Column 0
1
Row 3, Column 1
2
Row 3, Column 2
3
Row 3, Column 3
4
Row 3, Column 4
NA
Row 3, Column 5
0
Row 4, Column 0
1
Row 4, Column 1
2
Row 4, Column 2
3
Row 4, Column 3
4
Row 4, Column 4
NA
Row 4, Column 5
0
Row 5, Column 0
1
Row 5, Column 1
2
Row 5, Column 2
3
Row 5, Column 3
4
Row 5, Column 4
NA
Row 5, Column 5
0
Row 6, Column 0
1
Row 6, Column 1
2
Row 6, Column 2
3
Row 6, Column 3
4
Row 6, Column 4
NA
Row 6, Column 5
0
Row 7, Column 0
1
Row 7, Column 1
2
Row 7, Column 2
3
Row 7, Column 3
4
Row 7, Column 4
NA
Row 7, Column 5
0
Row 8, Column 0
1
Row 8, Column 1
2
Row 8, Column 2
3
Row 8, Column 3
4
Row 8, Column 4
NA
Row 8, Column 5
0
Row 9, Column 0
1
Row 9, Column 1
2
Row 9, Column 2
3
Row 9, Column 3
4
Row 9, Column 4
NA
Row 9, Column 5
0
Row 10, Column 0
1
Row 10, Column 1
2
Row 10, Column 2
3
Row 10, Column 3
4
Row 10, Column 4
NA
Row 10, Column 5
0
Row 11, Column 0
1
Row 11, Column 1
2
Row 11, Column 2
3
Row 11, Column 3
4
Row 11, Column 4
NA
Row 11, Column 5
0
Row 12, Column 0
1
Row 12, Column 1
2
Row 12, Column 2
3
Row 12, Column 3
4
Row 12, Column 4
NA
Row 12, Column 5
0
Row 13, Column 0
1
Row 13, Column 1
2
Row 13, Column 2
3
Row 13, Column 3
4
Row 13, Column 4
NA
Row 13, Column 5
0
Row 14, Column 0
1
Row 14, Column 1
2
Row 14, Column 2
3
Row 14, Column 3
4
Row 14, Column 4
NA
Row 14, Column 5
0
Row 15, Column 0
1
Row 15, Column 1
2
Row 15, Column 2
3
Row 15, Column 3
4
Row 15, Column 4
NA
Row 15, Column 5
0
Row 16, Column 0
1
Row 16, Column 1
2
Row 16, Column 2
3
Row 16, Column 3
4
Row 16, Column 4
NA
Row 16, Column 5
0
Row 17, Column 0
1
Row 17, Column 1
2
Row 17, Column 2
3
Row 17, Column 3
4
Row 17, Column 4
NA
Row 17, Column 5
1 of 18
15
Thank you for your invaluable input. Please feel free to add any comments below.
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