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conners test used to measure adhd symptons
Typology: Exams
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Name of Child: ____________________________________________________________ DOB: _____________
Name of Parent Completing Form: _______________________________________________________________
Please answer all questions. Beside each item below, indicate the degree of the problem by a check mark.
Not at all.
Just a little.
Pretty much.
Very much.
South East Bay Pediatrics (12/04)
South East Bay Pediatrics (12/04)
Performance Excellent^ Above Average
Average Somewhat of a Problem
Problematic
Overall school performance 1 2 3 4 5 Reading 1 2 3 4 5 Writing 1 2 3 4 5 Mathematics 1 2 3 4 5 Relationship with parents 1 2 3 4 5 Relationship with siblings 1 2 3 4 5 Relationship with peers 1 2 3 4 5 Participation in organized activities. 1 2 3 4 5
Severity or Impairment Considering your total experience with this child, how severely impaired is he/she at this time? Compare this child to average normal children you are familiar with from your totality of experience. Please circle the number that best describes this child. Normal, No Impairment 1
Symptoms are not present any more than expected (of a typical child of the same age and gender in the same situations) and do not produce impairment of normal functioning at home or at school. Slight Impairment 2
Symptoms are present a little more frequently or intensely than expected (of a typical child of the same age and gender in the same situations) and only rarely produce impairment of normal functioning at home or school. Mild Impairment 3
Symptoms are present somewhat more frequently or intensely than expected (of a typical child of the same age and gender in the same situations) and only sometimes produce impairment of normal functioning at home or school. Moderate Impairment 4
Symptoms are present a lot more frequently or intensely than expected (of a typical child of the same age and gender in the same situations) and usually produce impairment of normal functioning at home or school. Severe Impairment 5
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 situations) and most of the time produce impairment of normal functioning at home or school. Very Severe Impairment 6
Symptoms are present so much more frequently or intensely than expected (of a typical child of the same age and gender in the same situations) that they almost always produce impairment of normal functioning at home or school. Maximal, Profound Impairment 7
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.
South East Bay Pediatrics (12/04)