A chart to keep track of a child’s ADHD symptoms.
© Martin L Kutscher, MD.
May copy for patient use.
Please rate the severity of each problem listed.
(0)none (1)slight (2)moderate (3)major
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)|
|Homework not handed in|
|Inconsistent work and effort|
|Poor sense of time|
|Does not seem to talk through problems|
|Blows up easily|
|Trouble switching activities|
|Hyper-focused at times|
|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|
If the child is on medication, please answer the following questions: