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ADHD Behavioral Checklist PDF Print E-mail
(2 votes, average 3.00 out of 5)
Disorders - Attention Deficit Hyperactivity Disorder
Written by Martin L. Kutscher, MD   
Friday, 13 February 2009 06:53

A chart to keep track of a child's ADHD symptoms.

Book Excerpt from the ADHD e-BOOK

© Martin L Kutscher, MD.
May copy for patient use.

Child's Name:
Date:
Please rate the severity of each problem listed.
(0)none (1)slight (2)moderate (3)major		Your Name:
Subject (if teacher):
Please add comments below!
Symptom DescriptionDay 1Day 2Day 3Day 4Day 5Day 6Day 7
Trouble attending to work that child understands well       
Trouble attending to work that child understands poorly       
       
Impulsive (trouble waiting turn, blurts out answers)       
Hyperactive (fidgity, trouble staying seated)       
Disorganized       
Homework not handed in       
Inconsistent work and effort       
Poor sense of time       
Does not seem to talk through problems       
Over-reacts       
Easily overwhelmed       
Blows up easily       
Trouble switching activities       
Hyper-focused at times       
Poor handwriting       
Certain academic tasks seem difficult (specifiy)       
Seems deliberately spiteful, cruel or annoying       
Anxious, edgy, stressed or painfully worried       
Obsessive thoughts or fears; perseverative rituals       
Irritated for hours or days on end (not just frequent, brief blow-ups)       
Depressed, sad, or unhappy       
Extensive mood swings       
Tics: repetitive movements or noises       
Poor eye contact       
Does not catch on to social cues       
Limited range of interests and interactions       
Unusual sensitivity to sounds, touch, textures, movement or taste       
Coordination difficulties       
Other (specify)       

If the child is on medication, please answer the following questions:

  1. Can you tell when the child is on medication or not?
  2. Does the medication work consistently throughout the day?
  3. Does the child appear to be on too much or too little medication?
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