Behavioral Assessment Checklist Form

Chief Complaint

Behavioral Assessment Checklist Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Behavioral Assessment Checklist 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 40 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? Inattention Symptoms: 1. How often do you fail to give close attention to details or make careless mistakes in schoolwork or tasks? 0 ~ 3 2. How often do you have difficulty sustaining attention in tasks or play activities? 0 ~ 3 3. How often do you not seem to listen when spoken to directly? 0 ~ 3 4. How often do you not follow through on instructions and fail to finish schoolwork, chores, or duties? 0 ~ 3 5. How often do you have difficulty organizing tasks and activities? 0 ~ 3 6. How often do you avoid, dislike, or reluctantly engage in tasks requiring sustained mental effort? 0 ~ 3 7. How often do you lose things necessary for activities (e.g., toys, school assignments, pencils, or books)? 0 ~ 3 8. How often are you distracted by extraneous stimuli? 0 ~ 3 9. How often are you forgetful in daily activities? 0 ~ 3 Hyperactivity/Impulsivity Symptoms: 10. How often do you fidget with hands or feet or squirm in your seat? 0 ~ 3 11. How often do you leave your seat in situations where remaining seated is expected? 0 ~ 3 12. How often do you run about or climb excessively in situations where it is inappropriate? 0 ~ 3 13. How often do you have difficulty playing or engaging in leisure activities quietly? 0 ~ 3 14. How often are you "on the go" or act as if "driven by a motor"? 0 ~ 3 15. How often do you talk excessively? 0 ~ 3 16. How often do you blurt out answers before questions have been completed? 0 ~ 3 17. How often do you have difficulty waiting your turn? 0 ~ 3 18. How often do you interrupt or intrude on others (e.g., butt into conversations or games)? 0 ~ 3 Oppositional Behavior Traits: 19. How often do you lose your temper? 0 ~ 3 20. How often do you argue with adults? 0 ~ 3 21. How often do you actively defy or refuse adult requests or rules? 0 ~ 3 22. How often do you deliberately do things that annoy other people? 0 ~ 3 23. How often do you blame others for your mistakes or misbehavior? 0 ~ 3 24. How often are you touchy or easily annoyed by others? 0 ~ 3 25. How often are you angry and resentful? 0 ~ 3 26. How often are you spiteful or vindictive? 0 ~ 3