Form 410 - Follow-Up Adhd Teacher Questionnaire Page 2
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1
2Follow-Up ADHD Teacher Questionnaire
(BLACK INK ONLY PLEASE)
Date: ___________________________
Name: ________________________________________________ DOB: _____________________ MRN _________________
Teacher: ______________________________________________ Subject: __________________________________________
PERFORMANCE
Problematic
Average
Above Average
1. Overall Academic Performance
1
2
3
4
5
a. Reading
1
2
3
4
5
b. Mathematics
1
2
3
4
5
c. Written Expression
1
2
3
4
5
2. Overall Classroom Performance
1
2
3
4
5
a. Relationship with Peers
1
2
3
4
5
b. Following Directions/Rules
1
2
3
4
5
c. Disrupting Class
1
2
3
4
5
d. Assignment Completion
1
2
3
4
5
e. Organizational Skills
1
2
3
4
5
Please include any observations you feel are pertinent:__________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please return this form to the student’s parent.
Form 410 ADHD Teacher Follow-Up Questionnaire
rev 3/08
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Parent category: Medical