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Below are a number of common problems that children have. Please rate each item according to your child's behavior in the last month. For each item, ask yourself, "How much of a problem has this been in the last month?", and circle the best answer for each one. If none, not at all, seldom, or very infrequently, you would circle 0. If very much true, or it occurs very often or frequently, you would circle 3. You would circle 1 or 2 for ratings in between. Please respond to each item.

1. Inattentive, easily distracted

Not True at All
Just a Little True
Pretty Much True
Very Much True

2. Angry and resentful

Not True at All
Just a Little True
Pretty Much True
Very Much True

3. Difficulty doing or completing homework

Not True at All
Just a Little True
Pretty Much True
Very Much True

4. Is always "on the go" or acts as if driven by a motor

Not True at All
Just a Little True
Pretty Much True
Very Much True

5. Short attention span

Not True at All
Just a Little True
Pretty Much True
Very Much True

6. Argues with adults

Not True at All
Just a Little True
Pretty Much True
Very Much True

7. Fidgets with hands or feet or squirms in seat

Not True at All
Just a Little True
Pretty Much True
Very Much True

8. Fails to complete assignments

Not True at All
Just a Little True
Pretty Much True
Very Much True

9. Hard to control in malls or while grocery shopping

Not True at All
Just a Little True
Pretty Much True
Very Much True

10. Messy or disorganized at home or school

Not True at All
Just a Little True
Pretty Much True
Very Much True

11. Loses temper

Not True at All
Just a Little True
Pretty Much True
Very Much True

12. Needs close supervision to get through assignments

Not True at All
Just a Little True
Pretty Much True
Very Much True

13. Only attends if it is something he/she is very interested in

Not True at All
Just a Little True
Pretty Much True
Very Much True

14. Runs about or climbs excessively in situations where it is inappropriate

Not True at All
Just a Little True
Pretty Much True
Very Much True

15. Distractibility or attention span a problem

Not True at All
Just a Little True
Pretty Much True
Very Much True

16. Irritable

Not True at All
Just a Little True
Pretty Much True
Very Much True

17. Avoids, expresses reluctance about, or has difficulties engaging in tasks that require sustained mental effort (such as schoolwork or homework)

Not True at All
Just a Little True
Pretty Much True
Very Much True

18. Restless in the "squirmy" sense

Not True at All
Just a Little True
Pretty Much True
Very Much True

19. Gets distracted when given instructions to do something

Not True at All
Just a Little True
Pretty Much True
Very Much True

20. Actively defies or refuses to comply with adults' requests

Not True at All
Just a Little True
Pretty Much True
Very Much True

21. Has trouble concentrating in class

Not True at All
Just a Little True
Pretty Much True
Very Much True

22. Has difficulty waiting in lines or awaiting turn in games or group situations

Not True at All
Just a Little True
Pretty Much True
Very Much True

23. Leaves seat in classroom or in other situations in which remaining seated is expected

Not True at All
Just a Little True
Pretty Much True
Very Much True

24. Deliberately does things that annoy other people

Not True at All
Just a Little True
Pretty Much True
Very Much True

25. 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)

Not True at All
Just a Little True
Pretty Much True
Very Much True

26. Has difficulty playing or engaging in leisure activities quietly

Not True at All
Just a Little True
Pretty Much True
Very Much True

27. Easily frustrated in efforts

Not True at All
Just a Little True
Pretty Much True
Very Much True

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