Getting Started

Questionnaire

Please read each of the following statements and rate your student by selecting a number from 0 to 4 for each statement. Be sure to complete all the items. When you have completed the Questionnaire we ask that you e-mail it back to us by clicking on the send button at the bottom. We will email you with the results. Please answer all 64 of the questions to the best of your ability. 

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COMPARED TO OTHER STUDENTS THE SAME AGE...

Name:     Required E-Mail:     Required Address:     Required City:     Required State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Required Zip Code:     Required Day Phone: Evening Phone: Message: 0 1 2 3 4 Q1 - Is careless 0 1 2 3 4 Q2 - Fidgets or squirms 0 1 2 3 4 Q3 - Swears or uses obscene language 0 1 2 3 4 Q4 - Often asks to have things repeated 0 1 2 3 4 Q5 - Has difficulty maintaining attention 0 1 2 3 4 Q6 - Overreacts 0 1 2 3 4 Q7 - Loses temper 0 1 2 3 4 Q8 - Has poor study and work habits 0 1 2 3 4 Q9 - Has difficulty organizing activities 0 1 2 3 4 Q10 - Leaves seat in class 0 1 2 3 4 Q11 - Argues with adults 0 1 2 3 4 Q12 - Reverses letters or words 0 1 2 3 4 Q13 - Fails to follow through on tasks 0 1 2 3 4 Q14 - Runs or climbs excessively 0 1 2 3 4 Q15 - Refuses adults' requests or rules 0 1 2 3 4 Q16 - Feels school work is too hard 0 1 2 3 4 Q17 - Takes a long time to complete tasks 0 1 2 3 4 Q18 - Has difficulty playing quietly 0 1 2 3 4 Q19 - Deliberately annoys others 0 1 2 3 4 Q20 - Does not complete assignments 0 1 2 3 4 Q21 - Avoids prolonged mental effort 0 1 2 3 4 Q22 - Answers before questions completed 0 1 2 3 4 Q23 - Blames others for mistakes 0 1 2 3 4 Q24 - Has difficulty remembering 0 1 2 3 4 Q25 - Is distracted by other activities 0 1 2 3 4 Q26 - Has difficulty waiting for turn 0 1 2 3 4 Q27 - Is angry and resentful 0 1 2 3 4 Q28 - Has difficulty learning math facts 0 1 2 3 4 Q29 - Does not listen 0 1 2 3 4 Q30 - Is touchy or easily annoyed by others 0 1 2 3 4 Q31 - Holds grudges and seeks revenge 0 1 2 3 4 Q32 - Difficulty with abstract concepts 0 1 2 3 4 Q33 - Poor spelling grades or test scores 0 1 2 3 4 Q34 - Worries about future events 0 1 2 3 4 Q35 - Poor reading comprehension 0 1 2 3 4 Q36 - Has poor handwriting 0 1 2 3 4 Q37 - Poor math grades or test scores 0 1 2 3 4 Q38 - Worries about past behaviors 0 1 2 3 4 Q39 - Makes spelling errors on assignments 0 1 2 3 4 Q40 - Squints, blinks, rubs eyes when reading 0 1 2 3 4 Q41 - Dislikes school 0 1 2 3 4 Q42 - Concerned about what others will think 0 1 2 3 4 Q43 - Difficulty sounding out unknown words 0 1 2 3 4 Q44 - Has difficulty hearing 0 1 2 3 4 Q45 - Makes grammatical errors 0 1 2 3 4 Q46 - Is overly concerned about him/herself 0 1 2 3 4 Q47 - Past ear infections or speech problems 0 1 2 3 4 Q48 - Has poor coordination 0 1 2 3 4 Q49 - Poor reading grades or test scores 0 1 2 3 4 Q50 - Needs reassurance in many areas of life 0 1 2 3 4 Q51 - Needs words repeated for spelling tests 0 1 2 3 4 Q52 - Has speech difficulties 0 1 2 3 4 Q53 - Receives low test scores 0 1 2 3 4 Q54 - Complains about physical discomforts 0 1 2 3 4 Q55 - Avoids reading 0 1 2 3 4 Q56 - Complains about eye strain or fatigue 0 1 2 3 4 Q57 - Has difficulty writing a paper 0 1 2 3 4 Q58 - Appears tense or unable to relax 0 1 2 3 4 Q59 - Reading is slow or choppy 0 1 2 3 4 Q60 - Is bothered by loud sounds 0 1 2 3 4 Q61 - Has poor vocabulary 0 1 2 3 4 Q62 - Fears taking tests 0 1 2 3 4 Q63 - Difficulty reading or spelling phonetically 0 1 2 3 4 Q64 - Skips words or lines when reading   We Respect Your Privacy. We do not share your information with anyone.