1. Does not work to potential in school, receives "not working to potential" teacher comments.

Yes No

2. Has short attention span unless very interested in a particular subject.

Yes No

3. Has a family history of Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, learning problems or substance abuse.

Yes No

4. Is easily distracted.

Yes No

5. Lacks attention to detail.

Yes No

6. Has sloppy handwriting.

Yes No

7. Has difficulty putting thoughts on paper.

Yes No

8. Has trouble listening carefully to directions.

Yes No

9. Frequently forgets or misplaces things.

Yes No

10. Skips around while reading.

Yes No

11. Has difficulty learning new games and new skills.

Yes No

12. Has poor listening skills.

Yes No

13. Transposes numbers, letters or words.

Yes No

14. Is restless or in constant motion, is always "on the go."

Yes No

15. Concentrates better when moving or fidgeting.

Yes No

16. Has trouble sitting still or sitting in one place too long.

Yes No

17. Has increased anxiety or nervousness.

Yes No

18. Has a history of bed wetting beyond the age 5.

Yes No

19. Has poor communication skills.

Yes No

20. Lacks tact, often spurting out the first thing that comes to mind.

Yes No

21. Acts impulsively or dangerously without considering the consequences.

Yes No

22. Is easily bored.

Yes No

23. Says things without thinking and later regrets having said them.

Yes No

24. Starts to answer questions before the questions are fully asked.

Yes No

25. Is impatient.

Yes No

26. Has trouble following verbal directions.

Yes No

27. Makes careless mistakes in schoolwork.

Yes No

28. Has tendency to embarrass others.

Yes No

29. Lies or steals on impulse.

Yes No

30. Has trouble maintaining an organized work or living area.

Yes No

31. Is often late.

Yes No

32. Procrastinates, especially with multi-faceted tasks.

Yes No

33. Is easily overwhelmed by everyday tasks.

Yes No

34. Has trouble getting started.

Yes No

35. Starts projects but does not finish them.

Yes No

36. Fails to finish schoolwork or chores.

Yes No

37. Is inconsistent with school performance.

Yes No

38. Spends excessive time on homework.

Yes No

39. Has a tendency to drift away.

Yes No

40. Has problems with self-esteem.

Yes No

41. Has a negative attitude.

Yes No

42. Has trouble maintaining friendships.

Yes No

43. Acts immature for age.

Yes No

44. Has trouble expressing thoughts and feelings.

Yes No

45. Is verbally or physically abusive.

Yes No

46. Avoids group activities or organized sports.

Yes No

47. Has a quick temper, is "short-fused."

Yes No

48. Has rage outbursts.

Yes No

49. Gets upset by minor annoyances.

Yes No

50. Is argumentative.

Yes No

51. Worries needlessly or excessively.

Yes No

52. Has tendency toward obsessive behavior.

Yes No

53. Turns words around in conversations.

Yes No

54. Performs poorly under pressure.

Yes No

55. Has difficulty reading unless very interested in the subject.

Yes No

56. Has difficulty falling asleep.

Yes No

57. Has difficulty waking up or feeling fully awake.

Yes No

58. Is frequently tired.

Yes No

59. Startles easily.

Yes No

60. Is sensitive to touch, clothes, noise or light.

Yes No

61. Is more comfortable moving than sitting still.

Yes No

62. Has moods swings from highs to lows.

Yes No

63. Has trouble planning a series of tasks or activities.

Yes No

64. Become upset easily, is "thin-skinned."

Yes No

65 Talks excessively.

Yes No

66. Fidgets, even when sitting quietly.

Yes No

67. Has difficulty waiting in turn during group activities.

Yes No

68. Frequently daydreams or "spaces out."

Yes No

69. "Blanks out" when taking tests or under pressure.

Yes No

70. Has low frustration tolerance.

Yes No

71. Has frequent behavior problems in school.

Yes No