Weekly ADHD Monitoring Form # 6178
David Rabiner, Ph.D.

Child's name: _____________________________     Teacher: _______________________    Date:______________

Teacher: Please answer the items below on your observations of this child during the past week. Note that for
items 1-12, high scores indicate problems while for items 13-15, low scores indicate problems.

  Weekly ADHD Monitoring Form Not at all Just a little Often Very Often
1. fidgets with hands or feet and squirms in seat        
2. difficulty remaining seated        
3. difficulty awaiting turn        
4. always "up and on the go" or acts as if "driven by a motor"        
5. talks excessively        
6. interrupts or intrudes on others        
7. easily distracted        
8. fails to finish assigned tasks        
9. difficulty sustaining attention        
10.

careless or messy work
        
11.

does not seem to listen when spoken to        
12.

difficulty following directions        
13.

follows class rules        
14.

gets along with peers        
15.

seems happy and in a good mood        
16. Indicate how the behaviors rated on the other side compared during the morning and afternoon times during the prior week by checking one of the choices below. (Note: If you only have this child in class during morning or afternoon this does not apply)  __morning better than afternoon   ___no clear difference   ___afternoon better than morning
17. Indicate the approximate percentage of assigned class work that this child completed during the past week:
          ___________________________________________________________________________________
          0%                      20%                      40%                      60%                      80%                      100%
18. The general quality of work completed by this child this week was:
       ___ very poor           ___poor          ___satisfactory          ___good          ___very good
19. If the quality of this child's work varied significantly between subjects, please indicate this below.
20. Did this child turn in all assigned homework? If not, please indicate the assignments that were missing.
21. Please include any other comments or observations that you believe are important.
  From: David Rabiner. The ADHD Monitoring System. Copyright 1999 by David Rabiner. This form may be reproduced by myADHD.com active members for their personal use.

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