Attention trial

Chief Complaint

Attention and Behavior Assessment Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Attention and Behavior Assessment Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 5 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Attention and Behavior Assessment: 1. How often does the individual not pay attention to details or make careless mistakes, for example, in homework? 0 ~ 3 2. How often does the individual have difficulty keeping attention to what needs to be done? 0 ~ 3 3. How often does the individual not seem to listen when spoken to directly? 0 ~ 3 4. How often does the individual not follow through when given directions and fail to finish activities (not due to refusal or failure to understand)? 0 ~ 3 5. How often does the individual have difficulty organizing tasks and activities? 0 ~ 3 6. How often does the individual avoid, dislike, or not want to start tasks that require ongoing mental effort? 0 ~ 3 7. How often does the individual lose things necessary for tasks or activities (e.g., toys, assignments, pencils)? 0 ~ 3 8. Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.