SAMPLE BEHAVIORAL CHECKLIST

Child's Name: Date: Please rate the severity of each problem listed. (0)none (1)slight (2)moderate (3)major		Your Name: Subject (if teacher): Please add comments below!
Symptom Description	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Trouble attending to work that child understands well
Trouble attending to work that child understands poorly
Impulsive (trouble waiting turn, blurts out answers)
Hyperactive (fidgity, trouble staying seated)
Disorganized
Homework not handed in
Inconsistent work and effort
Poor sense of time
Does not seem to talk through problems
Over-reacts
Easily overwhelmed
Blows up easily
Trouble switching activities
Hyper-focused at times
Poor handwriting
Certain academic tasks seem difficult (specifiy)
Seems deliberately spiteful, cruel or annoying
Anxious, edgy, stressed or painfully worried
Obsessive thoughts or fears; perseverative rituals
Irritated for hours or days on end (not just frequent, brief blow-ups)
Depressed, sad, or unhappy
Extensive mood swings
Tics: repetitive movements or noises
Poor eye contact
Does not catch on to social cues
Limited range of interests and interactions
Unusual sensitivity to sounds, touch, textures, movement or taste
Coordination difficulties
Other (specify)

If the child is on medication, please answer the following questions:

1. Can you tell when the child is on medication or not?
2. Does the medication work consistently throughout the day?
3. Does the child appear to be on too much or too little medication?