ADHD &

YOU
ADHD Symptoms of Hyperactivity/Impulsivity
Never Sometimes Often Almost
Always
Does your child fidget with his/her
hands or feel when seated?
Does your child leave his/her seat in
situations where remaining seated
is expected?
Does your child feel restless or
move about excessively?
Does your child have difficulty
engaging in leisure activities
quietly?
Is your child often “on the go” or
feel like a motor drives them?
Does your child talk excessively?
Does your child blurt out answer
before question have been
completed?
Does your child have difficulty
waiting his/her turn?

Does your child interrupt or intrude

on others?
Choose the answer that is most appropriate for your child.

At School
At Home At School and at Home
These symptoms affect my child the most

Note: This checklist is not intended to take the place to a health care professional about your child’s ADHD
symptoms.

 ADHD & YOU
CHILD ADHD SYMPTOM CHECKLIST
Take a few minutes to complete this checklist so you can provide a detailed
description of
your child’s ADHD symptoms to the health care professional. It is not meant to
replace
consultation with a trained health care professional. An accurate diagnosis can be
made only
through a clinical evaluation. Regardless of the questionnaire results, if you have
concerns about diagnosis and treatment of ADHD, please discuss your concerns with
your physician.

ADHD Symptoms of Inattention

Never Sometimes Often Almost
Always
Does your child have difficulty paying
attention to details or make careless
mistakes?
Is it difficult for your child to sustain
attention during tasks and activities?
Does your child have trouble listening
when spoken to directly?
Is it difficult for your child to follow
through on instruction and finish work
at school or at home?
Does your child have trouble
organizing tasks and activities?
Does your child avoid tasks that require
sustained concentration or mental effort?
Does your child often misplace items
necessary for tasks or activities?
Is your child easily distracted by what’s
going on around them?
Is your child forgetful in daily activities?
Note: This checklist is not intended to take the talking to a health care professional about your child’s ADHD
symptoms.