Parent-Teacher Questionnaire

THIS QUESTIONAIR IS FOR PARENTS AND TEACHERS WHO SUSPECT A CHILD MAY HAVE PROBLEMS WITH ATTENTION. PLEASE RETURN TO:

Each gives a score of:
0 = not at all, 1 = just a little, 2 = Pretty much, and 3 = Very much.

PARENT'S EVALUATION	TEACHER'S EVALUATION
1. Excitable, impulsive ( )	1. Excitable, impulsive ( )
2. Difficulty in learning ( )	2. Difficulty in learning ( )
3. Restless, squirmy ( )	3. Restless, squirmy ( )
4. Restless, on the go ( )	4. Restless, on the go ( )
5. Doesn't finish things ( )	5. Doesn't finish things ( )
6. Childish, immature ( )	6. Childish, immature ( )
7. Short attention span ( )	7. Short attention span ( )
8. Easily frustrated ( )	8. Easily frustrated ( )
9. Quick mood changes ( )	9. Disturbs other children ( )
10. Denies mistakes ( )	10. Demands quick attention ( )
Total ( )	Total ( )
Combined total ( )

SCORING:
Add up the total score of the parent's questionnaire.
Add up the total score of the teacher's questionnaire.
Now add the two scores together for a Combined total.

If the combined total is 36 or more, there is a HIGH PROBABILITY THAT THE CHILD HAS ATTENTION DEFICIT DISORDER AND COULD BENEFIT FROM TREATMENT.

(Scores of 15 by the parent alone or 15 by the teacher alone should be considered a possibility