Putnam Valley Pediatrics
ADHD On-Line Teacher's Followup Questionnaire
(For Currently Registered Participants Only)
( * = Required Field)
1. What is the student's Registration Code ? *
1a. For confirmation, what is the student's date of birth (mm/dd/yy) ? *
2. Is this evaluation based on a time when the student was: Was on medication Was not on medication Not sure...
SYMPTOMS
Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since last rating you did, or roughly over the last month of classes or so.
If your answer is: "Never" -- enter "0"
"Occasionally" -- enter "1"
"Often" -- enter "2"
"Very Often" -- enter "3"
3. Does not pay attention to details or makes careless mistakes with, for example, homework
4. Has difficulty keeping attention to what needs to be done
5. Does not seem to listen when spoken to directly
6. Does not follow through when given directions and fails to finish activities (not due to refusal or misunderstand)
7. Has difficulty organizing tasks and activities
8. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
9. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
10. Is easily distracted by noises or other stimuli
11. Is forgetful in daily activities
12. Fidgets with hands or feet, or squirms in seat
13. Leaves seat when remaining seated is expected
14. Runs about or climbs excessively when remaining seated is expected
15. Has difficulty playing or beginning quiet play activities
16. Is "on the go" or often acts as if "driven by a motor"
17. Talks too much
18. Blurts out answers before questions have been completed
19. Has difficulty waiting his/her turn
20. Interrupts of intrudes in on others' conversations or activities
PERFORMANCE
If your answer is: "Excellent" -- enter "1"
"Above Average" -- enter "2"
"Average" -- enter "3"
"Somewhat of a problem" -- enter "4"
"Problematic" -- enter "5"
SEVERITY OF IMPAIRMENT
26. Please select one of the following statements:
NORMAL/NO IMPAIRMENT: Symptoms are not present any more than expected (of a typical child of the same age and gender in the same situation) and do not produce impairment of normal functioning at home or at school.
SLIGHT IMPAIRMENT: Symptoms are present a little more frequently or intensely than expected (of a typical child of the same age and gender in the same situation) and only rarely produce impairment of normal functioning at home or at school.
MILD IMPAIRMENT: Symptoms are present somewhat more frequently or intensely than expected (of a typical child of the same age and gender in the same situation) and only sometimes produce impairment of normal functioning at home or at school.
MODERATE IMPAIRMENT: Symptoms are present a lot more frequently or intensely than expected (of a typical child of the same age and gender in the same situation) and usually produce impairment of normal functioning at home or at school.
SEVERE IMPAIRMENT: Symptoms are present a great deal more frequently or intensely than expected (of a typical child of the same age and gender in the same situation) and most of the time produce impairment of normal functioning at home or at school.
VERY SEVERE IMPAIRMENT: Symptoms are present so much more frequently or intensely thank expected (of a typical child of the same age and gender in the same situation) that they almost always produce impairment of normal functioning at home or at school.
MAXIMAL, PROFOUND IMPAIRMENT: Symptoms are present so frequently or intensely that they produce significant and pervasive impairment, which creates a crisis requiring immediate action to prevent serious deterioration, to avoid danger, or to prevent harm.
PITTSBURGH SIDE-EFFECTS RATING SCALE
Instructions: Listed below are several possible negative effects (side effects) that medication may have on a child with ADHD. Please read each item carefully and select the appropriate rating that indicates if the severity of the side effect is None, Mild, Moderate, or Severe. Please think about your contact with your child today when rating his/her side effects.
When requested, or wherever you feel it would be useful for us to know, please describe the side effects that you observed or any other unusual behaviors in the Comments section below. The same person should complete this scale each time it is completed. Please use the following in deciding the severity of the side effects your child may be experiencing:
NONE: The symptom is assessed and found absent
MILD: The symptom is present but it is not sufficient to cause concern to the child, his/her peers, or adults, and would not affect a decision to recommend medication.
MODERATE: The symptom causes impairment of functioning or social embarrassment to a degree that the benefits of medication must be considerable to justify the risks of continuing medication.
SEVERE: The symptom causes impairment of functioning or social embarrassment to a degree that the child should not continue to receive the current medication as part of his/her treatment.
Side Effect
27. Comments:
28. Person completing form:
29. Choose: Telephone number to contact you:
Or 29a. E-Mail address to contact you:
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