Professional Documents
Culture Documents
Patient’s name:
Name:……………………………………………………………………………
Date:……………………………………….
Instructions: For each behavioral description listed, place a circle around the response that most
appropriately identifies patients/your behaviors.
7 Throws tantrums 0 1 2 3
1
Avoids new challenges because of lack of faith in his/her (self) 0 1 2 3
0
1
Appears restless inside even when sitting still 0 1 2 3
1
1
Is distracted by sights or sounds when trying to concentrate 0 1 2 3
2
1
Is forgetful in daily activities 0 1 2 3
3
1
Has trouble listening to what other people are saying 0 1 2 3
4
1 Is an underachiever 0 1 2 3
1
5
1
Is always on the go 0 1 2 3
6
1
Can’t get things done unless there is an absolute deadline 0 1 2 3
7
1
Fidgets (with hands or feet) or squirms in seat 0 1 2 3
8
1
Makes careless mistakes or has trouble on details. 0 1 2 3
9
2
Intrudes on other’s activities 0 1 2 3
0
2
Is restless or overactive 0 1 2 3
2
2
Can’t keep his/her mind on something unless it’s really interesting 0 1 2 3
4
2
Has trouble finishing job tasks or schoolwork 0 1 2 3
6
2
Interrupts others when they are working or busy 0 1 2 3
7
2
Expresses lack of confidence in self because of past failures 0 1 2 3
8
2
Appears distracted when things are going on around him/her 0 1 2 3
9
3
Has problems organizing tasks and activities 0 1 2 3
0