UPDOX - PATIENT PORTAL

Name * DOB * 1. Fails to give close attention to detail or makes careless mistakes in school, chores, or other activities? * 2. Has difficulty maintaining attention in school, task or activities not of interest to the child? * 3. Does not seem to listen when spoken to directly? * 4. Does not follow through on instructions or fails to finish schoolwork, chores, or projects? * 5. Has difficulty organizing self, tasks, or activites? * 6. Avoids, dislikes, or is reluctant to engage in tasks not of interest, that require sustained mental effort? * 7. Loses important or necessary items or belongings? * 8. During tasks not of interest to the child, easily distracted by extraneous, irrelevant, or unimportant stimuli? * 9. Forgetful in daily activities (where things are, what they were told or what they are supposed to be doing)? * 10. Fidgets with hands or feet, chews on fingers, clothes, or items, squirms in seat? * 11. Gets up out of seat in classroom or other situations in which remaining seated is expected? * 12. Runs or climbs excessively in inappropriate situations or in an inappropriate manner? * 13. Difficulty playing or engaging in leisure activities quietly or without excessive and unnecessary noise? * 14. Constantly busy or active, or has to be doing something or looking for something stimulating to do? * 15. Talks excessively, including asking questions to which they know the answer, but do not stop to think about it? * 16. Blurts out answers before questions are completed, or says things without thinking first? * 17. Difficulty awaiting turn, impatient when waiting, or does things impulsively without thinking first? * 18. Interrupts or intrudes on others, bulls into others conversations, games, activities, or personal space? * 1. Often loses temper? * 2. Often argues with adults? * 3. Often actively defies or refuses to comply with adults or request or rules? * 4. Often deliberately annoys people? * 5. Often blames others for his or her mistakes or misbehavior's? * 6. Is often touchy or easily annoyed by others? * 7. Is often angry and resentful? * 8. Is often spiteful or vindictive? * Electronic Signature of Parent or Guardian *