Record Your Child's Symptoms

It is important to share the information in this checklist with your child's doctor.
Once the symptom checklist is complete, click "Print" to receive a printer-friendly version of this checklist.

School	Never	Sometimes	Often	Very Often
Avoids or puts off tasks that require sustained mental effort or concentration
Makes careless mistakes in schoolwork
Frequently fails to finish schoolwork
Fidgets or squirms when seated, or leaves seat in classroom
Blurts out answers without raising hand

Home	Never	Sometimes	Often	Very Often
Cannot seem to sit still at mealtimes
Does not seem to listen when spoken to
Loses things such as toys, pencils, or books
Often runs or climbs excessively when not supposed to
Frequently forgets things he or she is supposed to do

Friends and Peers/Community	Never	Sometimes	Often	Very Often
Butts into conversations or games
Acts "on the go" or as if "driven by a motor"
Does not wait his or her turn during play or other activities
Talks excessively or constantly
Seems restless and fidgety while doing quiet activities

Please note: This symptom checklist does not replace a visit with a physician. If you have questions about the checklist or your answers, please consult a physician.