This form asks questions about your child’s behaviors. These behaviors may be true for every child at sometime in his or her life. Please read each question carefully and check off the box for the response that you believe is most true for your child during the past 6 MONTHS.

1. Fidget, is unable to sit still NeverSometimesOften

2. Act as if driven by a motor NeverSometimesOften

3. Daydreams too much NeverSometimesOften

4. Distract Easily NeverSometimesOften

5. Feel sad NeverSometimesOften

6. Feel hopeless NeverSometimesOften

7. Have trouble concentrating NeverSometimesOften

8. Fight with other children NeverSometimesOften

9. Feel down on him/herself NeverSometimesOften

10. Worry a lot NeverSometimesOften

11. Seem to having less fun NeverSometimesOften

12. Not listen to rules NeverSometimesOften

13. Not understand other people’s feelings NeverSometimesOften

14. Tease others NeverSometimesOften

15. Blame others for his/her troubles NeverSometimesOften

16. Refuse to share NeverSometimesOften

17. Take things that do not belong to him/her NeverSometimesOften