Clínica de Orientación Familiar y Asistencia Psicopedagógica

Tel. 236 6384

Sometime
Never or rarely often
s
1. Fails to give close attention to details or makes
careless mistakes in and and anschoolwork. 0 1 2 3

2. Fidgets with hands or feet or squirms in seat. 0 1 2 3

3. Has difficulty sustaining attention in tasks or play
activities. 0 1 2 3
4. Leaves seat in classroom or in other situations in
which remaining seated is and imexpected. 0 1 2 3

5. Does not seem to listen when spoken to directly. 0 1 2 3

6. Runs about or climbs excessively in situations in
which it is inappropriate. 0 1 2 3
7. Does not follow through on instructions and fails to
finish work. 0 1 2 3
8. Has difficulty playing or engaging in leisure activities
quietly. 0 1 2 3

9. Has difficulty organizing tasks and activities. 0 1 2 3

10. Is "on the go" or acts as if "driven by a motor." 0 1 2 3

11. Avoids tasks (e.g., schoolwork, homework) that
require sustained mental effort. 0 1 2 3

12. Talks excessively. 0 1 2 3

13. Loses things necessary for tasks or activities. 0 1 2 3

14. Blurts out answers before questions have been
completed. 0 1 2 3

15. Is easily distracted. 0 1 2 3

16. Has difficulty awaiting turn. 0 1 2 3

17. Is forgetful in daily activities. 0 1 2 3

18. Interrupts or intrudes on others. 0 1 2 3

 Clínica de Orientación Familiar y Asistencia Psicopedagógica
Tel. 236 6384

Rating Scale-IV -- School Version

Child's Name _________________________

Child's Age ________      Sex:  M      F      Grade________      Child's Race________

Circle the number that best describes this student's school behavior over the past 6 months (or
since the beginning of the school year).

never or
rarely sometimes often very often

1. Fails to give close attention to details or 0 1 2 3

makes careless mistakes in schoolwork.

2. Fidgets with hands or feet or squirms in seat. 0 1 2 3

3. Has difficulty sustaining attention in tasks or 0 1 2 3

play activities.

4. Leaves seat in classroom or in other 0 1 2 3

situations in which remaining seated is
expected.

5. Does not seem to listen when spoken to 0 1 2 3

directly.

6. Runs about or climbs excessively in 0 1 2 3

situations in which it is inappropriate.

7. Does not follow through on instructions and 0 1 2 3

fails to finish work.

8. Has difficulty playing or engaging in leisure 0 1 2 3

activities quietly.

9. Has difficulty organizing tasks and activities. 0 1 2 3

10. Is "on the go" or acts as if "driven by a 0 1 2 3

motor."

11. Avoids tasks (e.g., schoolwork, homework) 0 1 2 3

that require sustained mental effort.

12. Talks excessively 0 1 2 3

13. Loses things necessary for tasks or activities. 0 1 2 3

14. Blurts out answers before questions have 0 1 2 3

been completed.

15. Is easily distracted. 0 1 2 3

16. Has difficulty awaiting turn. 0 1 2 3

17. Is forgetful in daily activities. 0 1 2 3

18. Interrupts or intrudes on others. 0 1 2 3

 Clínica de Orientación Familiar y Asistencia Psicopedagógica
Tel. 236 6384

Child Attention Profile

Child's Name:  Age:

Filled Out By: Child's Sex: ___ M    ___F
Date:

DIRECTIONS:
Below is a list of items that describes pupils.  For each item that describes the pupil, now or within
the past week, check whether the item is Not True, Somewhat or Sometimes True, or Very or Often
True.  Please check all items as well as you can, even if some do not seem to apply to this pupil.

Not Somewhat or Very or

True Sometimes True Often True
1. Fails to finish things he/she starts [   ] [   ] [   ]
2. Can't concentrate, can't pay attention for long [   ] [   ] [   ]
3. Can't sit still, restless, or hyperactive [   ] [   ] [   ]
4. Fidgets [   ] [   ] [   ]
5. Daydreams or gets lost in his/her thoughts [   ] [   ] [   ]
6. Impulsive or acts without thinking [   ] [   ] [   ]
7. Difficulty following directions [   ] [   ] [   ]
8. Talks out of turn [   ] [   ] [   ]
9. Messy work [   ] [   ] [   ]
10. Inattentive, easily distracted [   ] [   ] [   ]
11. Talks too much [   ] [   ] [   ]
12. Fail to carry out assigned tasks [   ] [   ] [   ]

 Please feel free to write any comments about the pupil's work or behavior in the last week:
 Clínica de Orientación Familiar y Asistencia Psicopedagógica
Tel. 236 6384

  Rating Scale-IV -- Home Version

Child's Name _________________________

Child's Age ________      Sex:  M      F      Grade________      Child's Race________

Completed by:  Mother    Father    Guardian    Grandparent

Circle the number that best describes your child's home behavior over the last 6 months

never or
rarely sometimes often very often

1. Fails to give close attention to details or 0 1 2 3

makes careless mistakes in schoolwork.

2. Fidgets with hands or feet or squirms in seat. 0 1 2 3

3. Has difficulty sustaining attention in tasks or 0 1 2 3

play activities.

4. Leaves seat in classroom or in other 0 1 2 3

situations in which remaining seated is
expected.

5. Does not seem to listen when spoken to 0 1 2 3

directly.

6. Runs about or climbs excessively in 0 1 2 3

situations in which it is inappropriate.

7. Does not follow through on instructions and 0 1 2 3

fails to finish work.

8. Has difficulty playing or engaging in leisure 0 1 2 3

activities quietly.

9. Has difficulty organizing tasks and activities. 0 1 2 3

10. Is "on the go" or acts as if "driven by a 0 1 2 3

motor."

11. Avoids tasks (e.g., schoolwork, homework) 0 1 2 3

that require sustained mental effort.

12. Talks excessively 0 1 2 3

13. Loses things necessary for tasks or activities. 0 1 2 3

14. Blurts out answers before questions have 0 1 2 3

been completed.

15. Is easily distracted. 0 1 2 3

16. Has difficulty awaiting turn. 0 1 2 3

17. Is forgetful in daily activities. 0 1 2 3

18. Interrupts or intrudes on others. 0 1 2 3

 Clínica de Orientación Familiar y Asistencia Psicopedagógica
Tel. 236 6384

Connor's Abbreviated Rating Scale is shown below, a total of more than 15 is

suggestive ADD:

Not at all Just a Pretty Very much

Name:
(0) little much (3)
Date:
(1) (2)
Restless and overactive        
Excitable, impulsive        
Disturbs other children        
Fails to finish things.
       
Short attention span
Constantly fidgeting        
Inattentive, easily distracted        
Demands must be met
immediately        
Easily frustrated
Cries often and easily        
Mood changes quickly and
       
drastically
Temper outbursts, explosive
       
and unpredictable behavior
Clínica de Orientación Familiar y Asistencia Psicopedagógica
Tel. 236 6384