Parent Questionnaire

Messy handwriting

Holding pencil very tightly or near the tip

Difficulty drawing pictures or building things

Hand tires easily when writing

Drawing straight lines

Difficulty playing sports

Not coordinated

Difficulty with balance

Poor swimmer

Clumsy

Forgets what was recently said

Problems remembering where things were put

Difficulty remembering long instructions

Difficulty remembering names of people or things

Memory problems

Difficulty pronouncing many new words

Difficulty finding the right words to use

Difficulty explaining things or figuring out how to express ideas

Getting mixed up when people talk in long sentences

Difficulty talking or describing things smoothly

Getting confused about left and right

Keeping place in reading

Poor sense of direction; gets lost easily

Difficulty fixing things that break

Sometimes writing letters or numbers backwards

Getting mixed up about time and dates

Difficulty using directions to put something together

Difficulty judging distances

Getting confused when asked to do several things in correct order

Short attention span

Distractible

Impulsive – does things too quickly

Often blurts out things they shouldn’t say

Fidgety

Spacey; in own world; daydreams

Problems organizing and completing tasks, projects

Easily frustrated – gives up easily

Short fuse – loses temper easily

Problems with reading

Problems with mathematics

Problems with spelling

Is this evaluation based on a time when the child…

Does not pay attention to details or makes careless mistakes with, for example, homework

Has difficulty keeping attention to what needs to be done

Does not seem to listen when spoken to directly

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

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

Is easily distracted by noises or other stimuli

Is forgetful in daily activities

Fidgets with hands or feet or squirms in seat

Leaves seat when remaining seated is expected

Runs about or climbs too much when remaining seated is expected

Has difficulty playing or beginning quiet play activities

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

Talks too much

Blurts out answers before questions have been completed

Has difficulty waiting his or her turn

Interrupts or intrudes on others’ conversations and/or activities

Argues with adults

Loses temper

Actively defies or refuses to go along with adults’ requests or rules

Deliberatey annoys people

Blames others for his or her mistakes or misbehaviors

Is touchy or easily annoyed by others

Is angry or resentful

Is spiteful and wants to get even

Bullies, threatens, or intimidates others

Starts physical fights

Lies to get out of trouble or to avoid oblications (ie, “cons” others)

Is truant from school (skips school) without permission

Is physically cruel to people

Has stolen things that have value

Deliberately destroys others’ property

Has used a weapon that can cause serious harm (bat, knife, brick, gun)

Is physically cruel to animals

Has deliberately set fires to cause damage

Has broken into someone else’s home, business, or car

Has stayed out at night without permission

Has run away from home overnight

Has forced someone into sexual activity

Is fearful, anxious, or worried

Is afraid to try new things for fear of making mistakes

Feels worthless or inferior

Blames self for problems, feels guilty

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

Is sad, unhappy, or depressed

Is self-conscious or easily embarrassed

Overall school performance

Reading

Writing

Mathematics

Relationship with parents

Relationship with siblings

Relationship with peers

Participation in organized activities (eg, teams)

share fun activities with others?

use language that was immature for his/her age?

use an odd way of speaking?

become obsessed with details?

insist on doing things the same way each time?

play with others?

notice social cues?

show an interest in the ideas of others?

understand age-appropriate humor or jokes?

focus on one subject for too much time?

need things to happen just as expected?

insist on certain routines?

become upset if routines were changed?

show good peer interactions?

respond when spoken to by other children?

They notice and enjoy beauty in many places (nature, art, music, etc.).

They notice and enjoy watching people who are talented or very skilled at what they do.

They do not avoid challenges or difficult situations.

They speak up for what they think is right, even if others disagree with them.

They think of new and original ways of doing things.

They are able to think of many unique ways to solve problems.

They are interested in many things.

They like to explore and discover new things.

They give everyone a fair chance.

They treat others in a fair and just way.

They forgive those who have done or said hurtful things.

They give people a second chance.

They don’t hold grudges.

They notice the good thigns that happen.

They appreciate the good things that happen.

They take the time to express thanks to those who do nice things for them.

They are true to themselves.

They allow others to see the “real them.”

They speak the truth.

They take responsibility for what they do and say.

They don’t draw extra attention to themselves.

They let their accomplishments speak for themselves (rather than pointing them out).

They don’t see themselves as better than others.

They like to laugh and make others laugh.

They see the light side of things.

They enjoy helping others.

They enjoy taking care of other people.

They like to encourage and work with others to help get things done.

They like to organize group activities and help to make them happen.

They like being close to other people.

They like to give love to others.

They like receiving love from others.

They enjoy learning new information.

They enjoy learning how to do things.

They like to think things through before making a decision.

They look at all “sides” of a situation.

They are able to change their mind (if there is a good reason to do so).

They expect good things to happen in the future.

They work to make good things happen.

They finish what they start.

They find ways to overcome obstacles.

They enjoy completing tasks.

They are able to give people good advice.

They are able to see the “big picture.”

They are careful in making decisions.

They avoid taking unnecessary risks.

They avoid doing or saying things they might later regret.

They avoid “overdoing” things.

They avoid losing their temper.

They know what to do to get along with different groups of people.

They know what makes other people “tick”; they know why people do what they do.

They are aware of other peoples’ thoughts and feelings.

They feel they are here for a reason.

They feel a sense of connection with something larger than themselves.

They work well as a member of a group or team.

They always do their share of the work in a team or group.

They are loyal to groups or teams to which they belong.

They do things with energy and excitement.

They view life as an adventure.