Questionnaire

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Questionnaire

Find out if your daughter (or a young female student) shows signs of ADHD.

If she doesn’t have many symptoms now, it doesn’t rule out ADHD as these behaviors may be more apparent when the demands on her increase.

If she struggles with many of the behaviors listed below at home and school, at least three times a week, and the behaviors persist over time, discuss your concerns with your family physician.

A copy of your responses will be emailed to you.

Email *

I am a *

Parent

Educator

Therapist or health care professional

Other:

If other, please describe

I am completing this form on *

My daughter

A young female student

Other:

If other, please describe

What is your daughter (or young female student's) age? *

How did you find this questionnaire? Check all that apply. *

Social media

Print media

Educator recommended

Therapist or health care professional recommended

Other

Required

If other, please describe

Inattentiveness *

Makes careless mistakes in schoolwork

Frequently overlooks or misses details

Takes excessive time to complete tasks, such as self-care

Not applicable

Required

Difficulty Maintaining Attention *

Is easily distracted, especially in unstructured enviroments

Has trouble staying focused during tasks or conversations

Is quickly bored unless the subject interests her

Has an extreme focus on things that greatly interest her

Not applicable

Required

Poor Listening Skills *

Seems to be elsewhere, even without distractions

Requires frequent repetition of instructions

Engages in activities instead of listening

Has trouble following directions

Not applicable

Required

Organization and Forgetfulness *

Has a poor sense of time

Often forgets what someone said

Needs frequent reminders

Has difficulty with starting and completing task

Is disorganized and messy (in appearance and physical space

Frequently misplaces personal items

Not applicable

Required

Restlessness and Impulsivity *

Fidgets or squirms excessively

Leaves seat when expected to remain seated

Interrupts or butts in on others conversations or activities

Is often asked to quiet down

Quickly becomes impatient

Not applicable

Required

Emotional Dysregulation *

Gets upset or angry about minor things

Over-reacts to criticisms or perceived rejections

Cries easily or has meltdowns

Behaves well in school but is reactive and irritable upon arrival at home

Not applicable

Required

Socially Awkward *

Has difficulty making and keeping friends

Is agressive and bossy with peers

Is shy and introverted

Prefers solitary activities

Not applicable

Required

Anxious Behaviors *

Worries about school, studies or workload

Worries about others' opinions

Is reluctant to go to school or asks to stay home

Has trouble falling asleep at night

Not applicable

Required

Heightened Sensory Issues *

Is fussy about how clothing fits and feels

Can't tolerate certain food textures and tastes

Gets overwhelmned by loud or visually stimulating enviroments

Not applicable

Required

Comments and questions

*Additional behaviors sometimes observed in girls with ADHD: bedwetting, acting silly, nail biting, picking at cuticles or skin, and poor handwriting.

If your daughter frequently exhibits several of these behaviors and they interfere with her daily functioning, it is crucial to seek a professional evaluation.

Early diagnosis and appropriate interventions can significantly improve her academic and social outcomes.

Keep your responses to the questionnaire for future reference as occasionally the described behaviors will become noticeable when the demands on the child increase.

If your daughter doesn't have many symptoms now, it doesn't rule out ADHD in the future.

A copy of your responses will be emailed to the address you provided.

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