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


Child's name: _________________________             Date:__________________________

Teacher(s): ______________________________________________________________

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
Items

  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 coments 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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