Form 407 - Initial Adhd Evaluation Parent Questionnaire Page 3
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4Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
15. Talks too much
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16. Blurts out answers before questions have been completed
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17. Has difficulty waiting his/her turn
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18. Interrupts or intrudes on others (e.g., butts into conversations or games)
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19. Argues with adults
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20. Loses temper
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21. Actively defies or refuses to comply with adults’ requests or rules
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22. Deliberately annoys people
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23. Blames others for his or her mistakes or misbehaviors
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24. Is touchy or easily annoyed by others
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25. Is angry or resentful
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26. Is spiteful and vindictive
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27. Bullies, threatens, or intimidates others
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28. Initiates physical fights
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29. Lies to obtain goods for favors or to avoid obligations (i.e….”cons” others)
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30. Is truant from school (skips school) without permission
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31. Is physically cruel to people
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32. Has stolen items of nontrivial value
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33. Deliberately destroys others’ property
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34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
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35. Is physically cruel to animals
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36. Has deliberately set fires to cause damage
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37. Has broken into someone else’s home, business, or car
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38. Has stayed out at night without permission
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39. Has run away from home overnight
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40. Has forced someone into sexual activity
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41. Is fearful, anxious, or worried
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42. Is afraid to try new things for fear of making mistakes
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43. Feels worthless or inferior
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44. Blames self for problems, feels guilty
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45. Feels lonely, unwanted, or unloved: complains that “no one loves him/her”
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46. Is sad, unhappy, or depressed
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47. Is self-conscious or easily embarrassed
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Form 407 ADHD Parent Questionnaire
rev 3/08
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