Which office are you being treated in?* Toms River Freehold Child's Name* First Last Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent's Name* First Last Parent's Phone Number*Email* Today's Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DIRECTIONSEach rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months. 0 = Never 1 = Occasionally 2 = Often 3 = Very OftenIs this evaluation based on a time when the child* was on medication was not on medication not sure? SYMPTOMS1. Does not pay attention to details or makes careless mistakes with, for example, homework* 0 1 2 3 2. Has difficulty keeping attention to what needs to be done* 0 1 2 3 3. Does not seem to listen when spoken to directly* 0 1 2 3 4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)* 0 1 2 3 5. Has difficulty organizing tasks and activities* 0 1 2 3 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort* 0 1 2 3 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)* 0 1 2 3 8. Is easily distracted by noises or other stimuli* 0 1 2 3 9. Is forgetful in daily activities* 0 1 2 3 10. Fidgets with hands or feet or squirms in seat* 0 1 2 3 11. Leaves seat when remaining seated is expected* 0 1 2 3 12. Runs about or climbs too much when remaining seated is expected* 0 1 2 3 13. Has difficulty playing or beginning quiet play activities* 0 1 2 3 14. Is "on the go" or often acts as if "driven by a motor"* 0 1 2 3 15. Talks too much* 0 1 2 3 16. Blurts out answers before questions have been completed* 0 1 2 3 17. Has difficulty waiting his or her turn* 0 1 2 3 18. Interrupts or intrudes in on others’ conversations and/or activities* 0 1 2 3 19. Argues with adults* 0 1 2 3 20. Loses temper* 0 1 2 3 21. Actively defies or refuses to go along with adults’ requests or rules* 0 1 2 3 22. Deliberately annoys people* 0 1 2 3 23. Blames others for his or her mistakes or misbehaviors* 0 1 2 3 24. Is touchy or easily annoyed by others* 0 1 2 3 25. Is angry or resentful* 0 1 2 3 26. Is spiteful and wants to get even* 0 1 2 3 27. Bullies, threatens, or intimidates others* 0 1 2 3 28. Starts physical fights* 0 1 2 3 29. Lies to get out of trouble or to avoid obligations (ie, “cons” others)* 0 1 2 3 30. Is truant from school (skips school) without permission* 0 1 2 3 31. Is physically cruel to people* 0 1 2 3 32. Has stolen things that have value* 0 1 2 3 33. Deliberately destroys others’ property* 0 1 2 3 34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)* 0 1 2 3 35. Is physically cruel to animals* 0 1 2 3 36. Has deliberately set fires to cause damage* 0 1 2 3 37. Has broken into someone else’s home, business, or car* 0 1 2 3 38. Has stayed out at night without permission* 0 1 2 3 39. Has run away from home overnight* 0 1 2 3 40. Has forced someone into sexual activity* 0 1 2 3 41. Is fearful, anxious, or worried* 0 1 2 3 42. Is afraid to try new things for fear of making mistakes* 0 1 2 3 43. Feels worthless or inferior* 0 1 2 3 44. Blames self for problems, feels guilty* 0 1 2 3 45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"* 0 1 2 3 46. Is sad, unhappy, or depressed* 0 1 2 3 47. Is self-conscious or easily embarrassed* 0 1 2 3 PERFORMANCE1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic48. Overall school performance* 1 2 3 4 5 49. Reading* 1 2 3 4 5 50. Writing* 1 2 3 4 5 51. Mathematics* 1 2 3 4 5 52. Relationship with parents* 1 2 3 4 5 53. Relationship with siblings* 1 2 3 4 5 54. Relationship with peers* 1 2 3 4 5 55. Participation in organized activities (eg, teams)* 1 2 3 4 5 CommentsFOR OFFICE USE ONLYTotal number of questions scored 2 or 3 in questions 1–9Total number of questions scored 2 or 3 in questions 10–18Total Symptom Score for questions 1–18Total number of questions scored 2 or 3 in questions 19–26Total number of questions scored 2 or 3 in questions 27–40Total number of questions scored 2 or 3 in questions 41–47Total number of questions scored 4 or 5 in questions 48–55Average Performance Score Δ
