Confidential. Completed by the child's teacher at the parent's request, as part of a physician-led ADHD assessment. Please answer for the child's typical behaviour over the past 6 months, compared with other children the same age.
Child's name
Date of birth
Grade
Date completed
Teacher's name
How long have you taught this child?
Subjects / hours per week with this child
| How often does the child… | Never | Rarely | Sometimes | Often | Very often | |
|---|---|---|---|---|---|---|
| 1. | Has trouble keeping attention on tasks or play | Never | Rarely | Sometimes | Often | Very often |
| 2. | Makes careless mistakes in schoolwork | Never | Rarely | Sometimes | Often | Very often |
| 3. | Does not seem to listen when spoken to directly | Never | Rarely | Sometimes | Often | Very often |
| 4. | Starts tasks but has trouble finishing them | Never | Rarely | Sometimes | Often | Very often |
| 5. | Has trouble organizing tasks and activities | Never | Rarely | Sometimes | Often | Very often |
| 6. | Avoids or dislikes tasks that need sustained mental effort | Never | Rarely | Sometimes | Often | Very often |
| 7. | Loses things needed for tasks or activities | Never | Rarely | Sometimes | Often | Very often |
| 8. | Is easily distracted | Never | Rarely | Sometimes | Often | Very often |
| 9. | Is forgetful in daily activities | Never | Rarely | Sometimes | Often | Very often |
| How often does the child… | Never | Rarely | Sometimes | Often | Very often | |
|---|---|---|---|---|---|---|
| 10. | Fidgets or squirms when seated | Never | Rarely | Sometimes | Often | Very often |
| 11. | Leaves their seat when staying seated is expected | Never | Rarely | Sometimes | Often | Very often |
| 12. | Runs about or climbs in situations where it is not appropriate | Never | Rarely | Sometimes | Often | Very often |
| 13. | Has trouble playing quietly | Never | Rarely | Sometimes | Often | Very often |
| 14. | Is often "on the go," as if driven by a motor | Never | Rarely | Sometimes | Often | Very often |
| 15. | Talks excessively | Never | Rarely | Sometimes | Often | Very often |
| 16. | Blurts out answers before questions are finished | Never | Rarely | Sometimes | Often | Very often |
| 17. | Has trouble waiting their turn | Never | Rarely | Sometimes | Often | Very often |
| 18. | Interrupts or intrudes on others | Never | Rarely | Sometimes | Often | Very often |
How are these behaviours affecting the child's learning, behaviour at school, or friendships?
Anything else the physician should know (strengths, supports that help, changes over the year)?
Teacher's signature
School (name only — no board or address needed)
Return the completed form to the child's parent or guardian. It becomes part of the child's confidential medical record at olo (myolo.ca) and is reviewed only by the assessing physician. Questions about the assessment: the family can reach the clinic through their patient portal.