Teacher Follow-up Form

Teacher 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.
  • School currently attending.
  • Please enter a number from 00 to 12.
  • Date Format: DD slash MM slash YYYY
  • Please enter a number from 1 to 12.
  • Rating Scale
    NeverOccasionalOftenVery OftenNot Applicable
    . Does not pay attention to details or makes careless mistakes with, for example, homework
    2. Has difficulty keeping attention to what needs to be done
    3. Does not seem to listen when spoken to directly
    4. 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 activities
    6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
    7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
    8. Is easily distracted by noises or other stimuli
    9. Is forgetful in daily activities
    10. Fidgets with hands or feet or squirms in seat
    11. Leaves seat when remaining seated is expected
    12. Runs about or climbs too much when remaining seated is expected
    13. Has difficulty playing or beginning quiet play activities
    14. Is “on the go” or often acts as if “driven by a motor”
    15. Talks too much
    16. Blurts out answers before questions have been completed
    17. Has difficulty waiting his or her turn (waiting in line)
    18. Interrupts or intrudes on others’ conversations and/or activities
  • School work
    ExcellentAbove averageAverageSomewhat a ProblemProblematic
    19.Reading
    20. Mathematics
    21. Written Expression
    22. Relationship with peers
    23. Following direction
    24. Disrupting class
    25. Assignment completion
    26. Organizational skills
  • MedicationDosage per tabletDosage school morningDosage school Lunchtime 
    Name of medication, dose of each tablet, total dose per day
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