Columbus Pediatrics & Adolescent Care

Conners form

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click here to download printable form - the website version is distorted but it prints out correctly

For ADHD follow-up visits (after initial diagnosis) each ADHD f/u should have the following form filled out and brought at each visit.  During the school year, the teacher fills out the form.  When not in school, the parent fills out the form.  We give them at each visit, but if we forget or you lose them, you may print them out below.  We need to know how hour child is doing  morning and afternoon on average.

Conners Abbreviated Teacher's Rating Scale

Dear Teacher,

Please evaluate your student ____________________________using the following criteria.

Teacher's name________________________________

Time of day patient is taught by you:   ( )average am-noon                  ( )average noon - 3pm

Date______________

                                                         NOT AT                   JUST A                    PRETTY                          VERY

                                                           ALL                        LITTLE                   MUCH                           MUCH

OBSERVATIONS                             ________                  ______                  _______                  ________                                                                                                            

1.RESTLESS OR OVERACTIVE

 

2.EXCITABLE OR IMPULSIVE

 

3.DISTURBS OTHER CHILDREN

 

4.FAILS TO FINISH THINGS

HE STARTS. SHORT

ATTENTION SPAN

 

5.CONSTANTLY FIDGETING

 

6.INATTENTIVE, EASILY

DISTRACTED

 

7.DEMANDS MUST BE MET

IMMEDIATELY. EASILY

FRUSTRATED.

8.CRIES OFTEN AND EASILY.

 

9.MOOD CHANGES - QUICKLY

AND DRASTICALLY.

 

10.TEMPER OUTBURSTS,

EXPLOSIVE UNPREDICTABLE

BEHAVIOR

COMMENTS:

 

 These forms can be printed out by going to www.pedscpac.com.  Go to "Conners forms"

Columbus Pediatrics & Adolescent Care * 800 Jefferson St. Suite 116 * Whiteville, NC * 28472 *
*910 642-2642 *

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