Name of person you are rating:
Gender of person you are rating:
Your name:
Your relationship to the person you are rating:

Please rate the person initialed above by selecting the option that best describes the person's behavior during the past 6 months.

Items:Never or rarelySometimesOftenVery often
1. Fails to give close attention to details or makes careless mistakes in their work
2. Fidgets with hands or feet or squirms in seat
3. Has difficulty sustaining their attention in tasks or fun activities
4. Leaves their seat in situations in which seating is expected
5. Doesn't listen when spoken to directly
6. Seems restless
7. Doesn't follow through on instructions and fails to finish work
8. Has difficulty engaging in leisure activities or doing fun things quietly
9. Has difficulty organizing tasks and activities
10. Seems to be "on the go" or "driven by a motor"
11. Avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort
12. Talks excessively
13. Loses things necessary for tasks or activities
14. Blurts out answers before questions have been completed
15. Is easily distracted
16. Has difficulty awaiting turn
17. Is forgetful in daily activities
18. Interrupts or intrudes on others

How old was this person when these problems with attention, impulsiveness, or hyperactivity first began to occur? years old

To what extent do the problems you may have indicated above interfere with this person's ability to function in each of these areas of life activities?

Areas:Never or rarelySometimesOftenVery often
In their home life with their immediate family
In their work or occupation
In their social interactions with others
In their activities or dealings in the community
In any educational activities
In their dating or marital relationship
In their management of money
In their driving of a motor vehicle
In their leisure or recreational activities
In their management of their daily responsibilities

Instructions: Again, please indicate what best describes the person's behavior during the past six months.

Items:Never or rarelySometimesOftenVery often
1. Loses temper
2. Argues
3. Actively defies or refuses to comply with requests or rules
4. Deliberately annoys people
5. Blames others for their mistakes or misbehavior
6. Is touchy or easily annoyed by others
7. Is angry or resentful
8. Is spiteful or vindictive