Please enable JavaScript in your browser to complete this form.Name and relationship to patient *Telehealth appointment Provider *Patient Name *FirstLastDate of Birth *Email *1. Does not pay attention to details or makes careless mistakes with, for example, homeworkNeverOccasionallyOftenVery Often2. Has difficulty keeping attention to what needs to be doneNeverOccasionallyOftenVery Often3. Does not seem to listen when spoken to directlyNeverOccasionallyOftenVery Often4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)NeverOccasionallyOftenVery Often5. Has difficulty organizing tasks and activitiesNeverOccasionallyOftenVery Often6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effortNeverOccasionallyOftenVery Often7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)NeverOccasionallyOftenVery Often8. Is easily distracted by noises or other stimuliNeverOccasionallyOftenVery Often9. Is forgetful in daily activitiesNeverOccasionallyOftenVery Often10. Fidgets with hands or feet or squirms in seatNeverOccasionallyOftenVery Often11. Leaves seat when remaining seated is expectedNeverOccasionallyOftenVery Often12. Runs about or climbs too much when remaining seated is expectedNeverOccasionallyOftenVery Often13. Has difficulty playing or beginning quiet play activitiesNeverOccasionallyOftenVery Often14. Is “on the go” or often acts as if “driven by a motor”NeverOccasionallyOftenVery Often16. Blurts out answers before questions have been completedNeverOccasionallyOftenVery Often17. Has difficulty waiting his or her turnNeverOccasionallyOftenVery Often18. Interrupts or intrudes in on others’ conversations and/or activitiesNeverOccasionallyOftenVery Often19. Overall school performanceExcellentAbove AverageAverageSomewhat of a ProblemProblematic20. ReadingExcellentAbove AverageAverageSomewhat of a ProblemProblematic21. WritingExcellentAbove AverageAverageSomewhat of a ProblemProblematic22. MathematicsExcellentAbove AverageAverageSomewhat of a ProblemProblematic23. Relationship with parentsExcellentAbove AverageAverageSomewhat of a ProblemProblematic24. Relationship with siblingsExcellentAbove AverageAverageSomewhat of a ProblemProblematic25. Relationship with peersExcellentAbove AverageAverageSomewhat of a ProblemProblematic26. Participation in organized activities (eg, teams)ExcellentAbove AverageAverageSomewhat of a ProblemProblematicSide Effects: Has your child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem? If yes, please answer questions below, if no, can skip questions below.YesNoHeadacheNoneMildModerateSevereStomachacheNoneMildModerateSevereChange of appetite—explain belowNoneMildModerateSevereTrouble sleepingNoneMildModerateSevereIrritability in the late morning, late afternoon, or evening—explain belowNoneMildModerateSevereSocially withdrawn—decreased interaction with othersNoneMildModerateSevereExtreme sadness or unusual cryingNoneMildModerateSevereDull, tired, listless behaviorNoneMildModerateSevereTremors/feeling shakyNoneMildModerateSevereRepetitive movements, tics, jerking, twitching, eye blinking—explain belowNoneMildModerateSeverePicking at skin or fingers, nail biting, lip or cheek chewing—explain belowNoneMildModerateSevereSees or hears things that aren’t thereNoneMildModerateSevereExplain/CommentsEmailSubmit
