Psychiatry ADHD Teacher Forms | UMCH Family Services

Teacher's Name*

First Last

Teacher's Email*

Class Time

Class Name/Period

Child's Name*

First Last

Grade Level

Directions

Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year.

Please indicate the number of weeks or months you have been able to evaluate the behaviors:

Is this evaluation based on a time when the child

was on medication
was not on medication
not sure

Symptoms

Fails to give attention to details or makes careless mistakes in schoolwork

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Has difficulty sustaining attention to tasks or activities

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Does not seem to listen when spoken to directly

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Has difficulty organizing tasks and activities

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Loses things necessary for tasks or activities (school assignments, pencils, or books)

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is easily distracted by extraneous stimuli

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is forgetful in daily activities

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Fidgets with hands or feet or squirms in seat

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

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

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Runs about or climbs excessively in situations in which remaining seated is expected

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Has difficulty playing or engaging in leisure activities quietly

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is “on the go” or often acts as if “driven by a motor”

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Talks excessively

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Blurts out answers before questions have been completed

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Has difficulty waiting in line

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Interrupts or intrudes on others (eg, butts into conversations/games)

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Loses temper

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Actively defies or refuses to comply with adult’s requests or rules

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is angry or resentful

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is spiteful and vindictive

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Bullies, threatens, or intimidates others

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Initiates physical fights

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is physically cruel to people

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Has stolen items of nontrivial value

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Deliberately destroys others’ property

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is fearful, anxious, or worried

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is self-conscious or easily embarrassed

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is afraid to try new things for fear of making mistakes

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Feels worthless or inferior

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Blames self for problems; feels guilty

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Feels lonely, unwanted, or unloved; complains that “no one loves him or her”

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Is sad, unhappy, or depressed

Never (0)
Occasionally (1)
Often (2)
Very Often (3)

Performance

Academic Performance

Reading

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Mathematics

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Written expression

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Classroom Behavioral Performance

Relationship with peers

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Following directions

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Disrupting class

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Assignment completion

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Organizational skills

Excellent
Above Average
Average
Somewhat of a Problem
Problematic

Comments