Teacher Follow-up FormTeacher Assessment form for second and subsequent Doctor consultations Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Teachers's Name* First Last Teacher's Email* Enter Email Confirm Email School Name*School currently attending.School Email* Enter Email Confirm Email Child's Name* First Last Grade*Please enter a number from 00 to 12.Today’s Date* Date Format: DD slash MM slash YYYY Please indicate in months time you have been able to evaluate the behaviours:Please enter a number from 1 to 12.Is this evaluation based on a time when the child is on medication?* was on medication was not on medication not sure?*Rating ScaleNeverOccasionalOftenVery OftenNot Applicable. Does not pay attention to details or makes careless mistakes with, for example, homework2. Has difficulty keeping attention to what needs to be done3. Does not seem to listen when spoken to directly4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).5. Has difficulty organizing tasks and activities6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)8. Is easily distracted by noises or other stimuli9. Is forgetful in daily activities10. Fidgets with hands or feet or squirms in seat11. Leaves seat when remaining seated is expected12. Runs about or climbs too much when remaining seated is expected13. Has difficulty playing or beginning quiet play activities14. Is “on the go” or often acts as if “driven by a motor”15. Talks too much16. Blurts out answers before questions have been completed17. Has difficulty waiting his or her turn (waiting in line)18. Interrupts or intrudes on others’ conversations and/or activities*School workExcellentAbove averageAverageSomewhat a ProblemProblematic19.Reading20. Mathematics21. Written Expression22. Relationship with peers23. Following direction24. Disrupting class25. Assignment completion26. Organizational skillsMedications*MedicationDosage per tabletDosage school morningDosage school Lunchtime Name of medication, dose of each tablet, total dose per dayExplain/Comments: Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.