Student:___________________________________________
DATE:___________________________
HYPERACTIVITY
Easily
distracted
: (Tally)
#of
prompts
to
refocus:
Difficulty
sustaining
attention:
(Tally)
IMPULSIVITY
#of
minutes
engaged
8:058:45
8:459:25
9:2510:05
10:0510:40
10:4011:20
11:2012:00
1212:40
12:4013:20
13:2013:35
13:3514:00
14:0014:45
14:5515:10
Grey-Hyperactivity
Green: Impulsivity
Makes
careless
mistakes:
(Tally)
#of Times
adult
intervened
Reluctant to
engage in
tasks that
require effort/
seem
challenging:
(Y/N)
Fidgets
with
hands/f
eet or
squirms
in seat:
(Tally)
Leaves seat
(when
remaining
seated is
expected:
(Tally)
TIRED?
Blurts out
answers/
interrupts:
(Tally)
Has difficulty
awaiting
turn:
TIRED
(YES/NO)