Questionnaire

Not self-motivated - difficulty working independently

Yes No

Loses place when reading

Yes No

Bumps into people and things frequently - loses balance

Yes No

Difficulty remembering 2 or 3 instructions

Yes No

Picky about clothes, foods, noise

Yes No

Difficulty putting story parts in order - what happened first, second, third

Yes No

Assignments/chores take a long time to complete

Yes No

Guesses words when reading

Yes No

Gives up easily - doesn’t give things his/her ‘best effort’

Yes No

Frequently says “What?” and often asks to have things repeated

Yes No

Repeats information over and over to remember it

Yes No

Slumps, sits on leg, or lays on table when working

Yes No

Difficulty remembering words that have been previously mastered

Yes No

Has difficulty hearing in a noisy classroom

Yes No

Has difficulty throwing and/or catching a ball or learning to ride a bike

Yes No

Misunderstands instructions - does something different than was asked (not out of defiance)

Yes No

Difficulty staying focused to complete a learning task

Yes No

Difficulty describing ‘What happened’

Yes No

You often remind him/her to “Look at me when I’m talking.”

Yes No

Difficulty organizing ideas when telling (or writing) a story - goes ‘on and on’ but has difficulty getting ‘to the point of the story’

Yes No

Difficulty estimating the amount of time needed for completing assignments - rushes to finish

Yes No

Difficulty turning off the television, computer, or other electronics with screens

Yes No

Loses train of thought if interrupted

Yes No

Difficulty remembering the spelling of a word to write it down if heard aloud or while copying from the white board - needs spelling repeated or looks up at the board several times to write it down

Yes No

Difficulty remembering to do all the parts of multi-step assignments

Yes No

Says (or believes) things like “I’m dumb”, I’ll never ‘get’ it, ….

Yes No

Difficulty paying attention to ‘boring’ things BUT having good attention for things that are interesting

Yes No

Does poorly on a test after studying hard and feeling well prepared

Yes No

Has difficulty staying seated for homework, dinner time, etc.

Yes No

Easily overwhelmed and frustrated by homework, schoolwork, or learning something new

Yes No

Can remember lines from movies, songs, etc. and likes to repeat them

Yes No

Difficulty remembering facts when having to use or combine new information - like getting confused solving math problems where s/he must remember a math fact as well as the order of the steps to solving the problem

Yes No

Blurts out answers

Yes No

Skips words, substitutes words, adds words when reading

Yes No

Difficulty organizing things like desk, backpack, toys

Yes No

Difficulty getting started on homework, chores, etc.

Yes No

Misses comprehension questions

Yes No

Difficulty finding belongings - loses things

Yes No

Has difficulty forming letters and spacing them when writing

Yes No

Behind grade level

Yes No

Directions

Mark each statement that applies to your child (even if only sometimes).

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