Questionnaire

The test consist of six simple questions. Please respond by check the box “N” for never; “R” for rarely; “S” for sometimes; “O” for often; or “V” for very often.

Name

First Name

Last Name

Number

Question 1

How often does your child have trouble wrapping up the final details of a task/assignment, once they complete challenging parts? Give a breif discription below.

Question 2

How often does your child have difficulty getting things in order when asked to perform a task that requires organization? Select option below.

Question 3

How often does your child have problems remembering simple instructions or turn in homewor? Select option below.

Question 4

When your child has a task that requires a lot of thought, how often does he or she avoid or delay getting started? Select option below.

Question 5

How often does your child fidget or squirm with their hands and feet when they have to sit down for an extended period? Select option below.

Question 6

How often does your child overly active, hyper and cannot stop moving, as if driven by a motor? Select option below.

If you answered “S,” “O,” or “V” for questions 1,2, or 3, give yourself one point for each. If you answered “O”, or “V” for questions 4,5, or 6, give yourself one point for each. Now add up your points. A score of 4 or higher is a positive score. That means you ought to consult with your healthcare provider and go on to the next step in the diagnostic process. Please be advised, this is not a diagnostic test. It’s just a brief screening tool.

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Questionnaire

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