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Does your child receive any of the following support services?

Medical History


Behaviour NeverSometimesOftenN/A
Inattentive, easily distracted
Forgets things s/he has already learned
Disturbs other children
Actively disobeys or refuses to comply with adults' requests
Is always "on the go" or acts as if driven by a motor
Has difficulty playing or engaging in leisure activities quietly
Cannot remain still
Spiteful or vindictive
Leaves seat when remaining seated is expected
Fidgets with hands or feet or squirms in seat
Not reading up to par
Argues with adults
Only pays attention to things s/he is really interested in
Has difficulty waiting his/her turn
Lacks interest in schoolwork
Distractibility or attention span a problem
Temper outbursts; explosive, unpredictable behavior
Runs about or climbs excessively where inappropriate
Poor in arithmetic
Interrupts or intrudes on others (e.g. Interrupts others' conversation or games)
Poor in spelling
Fails to finish things s/he starts
Doesn't follow through on instructions and fails to finish tasks (not due to oppositional behavior or failure to understand directions)
Excitable, impulsive
Non-compliance with medication
Self-harm behavior
Inconsistent school attendance

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