老师姓名-----------------------课时--------------------------------课目/课长---------

日期------------------------------学生姓名---------------------------------年级-----------------------

提示：在评估时要审慎。应鉴别此儿童的行为是否为与年龄相符的正常现象．而且应反映他开始入学以来的情况。在填写此表格时，并请指明这些症状已持续多长时间。

此评估建立于当你的小孩子　　――用药期间　　　――非用药期间　　――不肯定

1.不能仔细注意细节或常发生粗心大意所致的错误  0        1      2         3

2.在学习工作或活动时，注意力难以持久          0        1      2         3         

3.与之对话时,心不在焉,似听非听                                                           

4.不听从指令而难以完成各项工作和任务          0        1      2         3                                    

 (并非因为不理解教导)                                                                   

5.难以完成或组织各项工作和活动                0        1      2         3                                       

6.逃避，不喜欢或不愿参加那些需要精力          0        1      2         3                                     

  持久的工作或活动                                                                            

7.遗失作业或活动所需要的东西,如玩具,作业本，   0       1       2         3                                           

  铅笔或课本                                                                                

8.易因声音或其它外界刺激而分心                0        1      2         3                                                   

9.遗忘日常活动                               0        1       2        3                                                   

10.手或足有很多小动作或在座位扭动             0        1      2         3                                                    

11.在要求安坐的场合擅自离开座位               0        1      2         3                                                  

12.在要求坐好的场合奔来奔去或爬上爬下         0        1      2         3                                                  

13.不能安静地参加游戏或活动                   0        1      2         3                                                       

14.似被发动机驱动地一刻不停地活动             0        1      2         3                                                    

15.讲话过多                                   0        1      2         3                                                    

16.在他人问题还没问完时就急于回答             0        1      2         3                                                  

17.难以静侯轮换                              0        1      2         3                                                  

18.在他人交谈时插嘴或打断他人的活动           0        1      2         3                                               

19.发脾气                                    0        1       2        3                                                 

20.经常拒绝大人的要求或不听规劝               0        1      2         3                                                     

21.生气或愤恨                                0        1       2        3                                                       

22.不屑一顾或冷漠                            0        1       2        3                                                      

23.恃强凌辱弱，威胁或恐吓他人                 0        1      2         3                                                     

24.对他人躯体攻击                            0        1       2        3                                                      

25.为获得利益或逃避责任                       0        1      2         3 

  而说谎( 如:“坑”别人)                                                  

26.对人残忍                                  0        1       2        3                                                

36.阅读                        1        2           3          4        5                   

39.与同学关系                    1        2          3          4        5 

40.听从指令                      1        2           3          4        5                                                 

41.扰乱课堂秩序                  1        2           3          4        5                                                  

42.按时完成作业                  1        2           3          4        5         

43.组织技巧                      1        2           3          4        5                   

请将此表寄给:---------------------------------------------------------------------------------------------------

寄信地址:---------------------------------------------------------------------------------------------------------

以下为工作人员所填

问题1－9中得分为2或3共几项:--------------------------------------------------------------------------

问题10－18中得分为2或3共几项:-----------------------------------------------------------------------

问题1－18中共有几项阳性症状----------------------------------------------------------------------------

问题19－28中得分为2或3共几项:-----------------------------------------------------------------------

问题29－35中得分为2或3共几项:-----------------------------------------------------------------------

问题36－43中得分为4或5共几项:-----------------------------------------------------------------------