Home-School Diary

How to use this form
Use this form to monitor a child’s behaviour at school and at home. You can decide with the teacher to fill it on a daily or a weekly basis (preferably on the same day every week if it is filled on a weekly basis). Bring the forms with you when you go see the child’s doctor to inform him or her about the child’s well being.

Please remember that this is not a diagnostic tool: it was designed to help parents, caregivers and teachers monitor a child’s progress by tracking changes big and small. We hope you find it useful for encouraging a child with ADHD to strive for improvement.

How the scores work
There is no right or wrong score; instead, scores are used to monitor changes in behaviour. A higher score compared to previous days or weeks means that the child is improving.

Name: ________________________________
Date or week of: ________________________

To be filled out by the child’s teacher
Score the statements from “Never/seldom” to “Very often/frequent”; if you notice anything else worth mentioning or that warrants special monitoring, you can write it down in the boxes at the bottom of the chart.

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Behavioural assessment	Never/seldom	Occasionally	Often/ quite a bit	Very often/ frequent
Schoolwork is improving	0	1	2	3
Works better in groups (than before)	0	1	2	3
Noisy and excitable	3	2	1	0
Has frequent fights with classmates	3	2	1	0
Easily distracted from tasks	3	2	1	0
Difficult to contain during break times	3	2	1	0
Disturbs children around them	3	2	1	0
Unable to pay attention in class	3	2	1	0
Unable to complete homework	3	2	1	0
Unable to sit through a whole period	3	2	1	0
Total (add scores in each column)	____ +	____ +	____ +	____ =

One behaviour that needs work: ____________________________________ ____________________________________ ____________________________________	One behaviour that has improved: ____________________________________ ____________________________________ ____________________________________
Examples: Remembering to raise hand before asking a question; staying quiet during class for the whole day; having all necessary material on hand (i.e. not forgetting books at home or at school); not running inside school grounds; putting on coat and boots quietly, etc

To be filled out by the child’s parent or caregiver
Score the statements from “Never/seldom” to “Very often/frequent”; if you notice anything else worth mentioning or that warrants special monitoring, you can write it down in the boxes at the bottom of the chart.

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Behavioural assessment	Never/seldom	Occasionally	Often/ quite a bit	Very often/ frequent
Concentrates better	0	1	2	3
Gets along better with the family	0	1	2	3
Gets along better with friends	0	1	2	3
Able to sustain attention while playing	0	1	2	3
Talks less than usual with other children	0	1	2	3
Less fidgety	0	1	2	3
Able to complete tasks	0	1	2	3
Homework is improving	0	1	2	3
Able to sit and listen when spoken to	0	1	2	3
Can sit through meal times	0	1	2	3
Total (add scores in each column)	____ +	____ +	____ +	____ =

One behaviour that needs work: ____________________________________ ____________________________________ ____________________________________	One behaviour that has improved: ____________________________________ ____________________________________ ____________________________________
Examples: Getting dressed before having breakfast, making bed before going to school; sitting at table throughout breakfast; being ready to leave for school at scheduled time; sitting at table throughout dinner; taking plate to sink when finished; remembering to brush teeth before bed; going to bed at scheduled time, etc.