Patient Name:

Date of Birth: MRN/File No:

Physician Name: Date:

CADDRA Child Assessment Instructions

Your child is being assessed for Attention Deficit Hyperactivity Disorder (ADHD). You will be asked to complete forms in
order to provide your medical professional with information on how your child functions in different areas of life.

This information must be reviewed by a trained medical professional as part of an overall ADHD assessment.
ADHD is not identified just through questionnaires. Diagnosing ADHD is not a matter of simply recognizing certain
symptoms; a thorough medical evaluation is necessary to rule out other possible causes for your child's symptoms.

Your input is very important but don't worry about answering the questions incorrectly or be concerned that you might
'label' your child. There are no right or wrong answers. You will be asked questions about how your child functions in a
variety of different situations. If you are unsure of an answer, provide an answer which best describes your child a good
deal of the time in that particular situation. Individual questions are less important than the scale as a whole, and this
can only be properly evaluated by a trained professional.

If the child is living in two households, each household should complete these forms separately. It is important that
parents take the time to thoughtfully complete all the required questionnaires. This information on how your child
functions in different settings is essential. Therefore, it is also important that your child's teacher provides feedback.
Please give the teacher the indicated forms and the teacher instruction handout.

Additional testing may be recommended by your health professional. This is particularly important if a learning disorder,
speech disorder, or any other health condition is suspected.

If you were not given copies of the forms, instructions and handouts that you need, they can all be printed from the
CADDRA website (www.caddra.ca).

Forms
Note: Please fill in the forms required by your health professional and indicated below. You may be asked to fill in forms
in two different colours to demonstrate the differences in your child when on and off medication.

Document Name Recommended To be completed by:

forms Each Parent Teacher
Weiss Symptom Record 3 x x
Weiss Functional Impairment Rating Scale - Parent 2 x
ADHD Checklist (current symptoms) 3 x x
SNAP-IV-26 3 x x
CADDRA Teacher Assessment Form 1 x
CADDRA Patient ADHD Medication Form (if on medication) 2 x

Resources
Please read the information on ADHD as indicated by your health professional. The CADDRA ADHD Information and
Resources handout can be printed from the CADDRA website (www.caddra.ca).

129
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Weiss Symptom Record (WSR)

Instructions to Informant: Check the box that best # items

describes typical behavior scored 2 or 3
Instructions to Physician: Symptoms rated 2 or 3 Not at all Somewhat Pretty much Very much N/A (DSM
are positive and total count completed below (0) (1) (2) (3) Criteria)

ADHD COMBINED TYPE 314.01

6/9 IA & HI

ATTENTION 314.00

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails

to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted

Forgetful in daily activities /9 (6/9)

HYPERACTIVE/IMPULSIVE 314.01
Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn

Interrupting or intruding on others /9 (6/9)

OPPOSITIONAL DEFIANT DISORDER 313.81

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehaviour

Touchy or easily annoyed by others

Angry or resentful

Spiteful or vindictive
/8 (4/8)

100 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 1/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

TIC DISORDERS 307.2 SEVERITY

Repetitive involuntary movements (blinking, twitching)

Repetitive involuntary noises (throat clearing, sniffing)

CONDUCT DISORDER 312.8

Bullies, threatens, or intimidates others
Initiates physical fights

Has used a weapon (bat, brick, bottle, knife, gun)

Physically cruel to people

Physically cruel to animals

Stolen while confronting a victim

Forced someone into sexual activity

Fire setting with the intent of damage

Deliberately destroyed others' property

Broken into a house, building, or car

Often lies to obtain goods or benefits or avoid obligations

Stealing items of nontrivial value without confronting victim

Stays out at night despite prohibitions

Run away from home overnight at least twice

Truant from school
/15(3/15)
ANXIETY

Worries about health, loved ones, catastrophe 300.02

Unable to relax; nervous
300.81

Chronic unexplained aches and pains
300.30

Repetitive thoughts that make no sense

Repetitive rituals
300.01

Sudden panic attacks with intense anxiety 300.23

Excessively shy

Refusal to do things in front of others 309.21

Refusal to go to school, work or separate from others 300.29

Unreasonable fears that interfere with activities 312.39

Pulls out hair, eyebrows

Nail biting, picking

Refusal to talk in public, but talks at home mutism

DEPRESSION 296.2 (single) .3 (recurrent)

Has been feeling sad, unhappy or depressed Yes No Must be present

No interest or pleasure in life Yes No Must be present
Feels worthless

Has decreased energy and less productive

Hopeless and pessimistic about the future

Excessive feelings of guilt or self blame

Self-injurious or suicidal thoughts

WSR 2/5 101

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEPRESSION (CONT'D) SEVERITY

Social withdrawal

Weight loss or weight gain

5/9>2wks
Change in sleep patterns

Agitated or sluggish, slowed down

Decreased concentration or indecisiveness

Past suicide attempts # Serious

MANIA 296.0(manic) .6(mixes) .5(depressed)

Distinct period of consistent elevated or irritable mood Yes No Must be present

Grandiose, sudden increase in self esteem

Decreased need for sleep

Racing thoughts

Too talkative and speech seems pressured

Sudden increase in goal directed activity, agitated 3 >1wk

High risk activities (spending money, promiscuity) /3 (3)

SOCIAL SKILLS 299

Makes poor eye contact or unusual body language

Failure to make peer relationships

Lack of spontaneous sharing of enjoyment

Lacks reciprocity or sensitivity to emotional needs of others

Language delay or lack of language communication

Difficulty communicating, conversing with others

Speaks in an odd, idiosyncratic or monotonous speech

Lack of creative, imaginative play or social imitation

Intensely fixated on one particular interest

Rigid sticking to nonfunctional routines or rituals

Preoccupied with objects and parts of objects

Repetitive motor mannerisms (hand flapping, spinning)

PSYCHOSIS 295
Has disorganized, illogical thoughts

Hears voices or sees things

Conviction that others are against or will hurt them

People can read their thoughts, or vice versa

Belief that the television is talking specifically to them

A fixed belief that is out of touch with reality

Thought sequence does not make sense

102 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 3/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

SUBSTANCE ABUSE SEVERITY
Excessive alcohol (> 2 drinks/day, > 4 drinks at once) 305
Smokes cigarettes

Daily marijuana use

Use of any other street drugs

Abuse of prescription drugs

SLEEP DISORDERS 307.4

Agitated or sluggish, slowed down
Has difficulty falling asleep

Has difficulty staying asleep

Has abnormal sleep patterns during the day 347

Unanticipated falling asleep during the day 307.4

Sleep walking
307.4

Has nightmares
307.45

Falls asleep late and sleeps in late 3.27

Sleep schedule changes from day to day

Excessive snoring

A feeling of restless legs while trying to sleep

Observed to have sudden kicking while asleep 780.57

Observed to have difficulty breathing at night

ELIMINATION DISORDERS 307

Wets the bed at night

Wets during the day

Soils self
EATING DISORDERS 307

Vomits after meals or binging

Underweight and refuses to eat
307.1

Distorted body image

Picky eater

High junk food diet

LEARNING DISABILITIES 315

Delayed expressive language

Stuttering

Problems articulating words
315

Below grade level in reading
315.1

Below grade level in math
315.2

Trouble with writing (messy, tiring, avoids writing)

Variable performance in school

Underachieves at school relative to potential

315.4

WSR 4/5 103

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEVELOPMENTAL COORDINATION DISORDER

Difficulty with gross motor skills (i.e. gym, sports, biking)

Clumsy

Difficulty with fine motor (buttons, shoe laces, cutting)

PERSONALITY 301 SEVERITY

Unstable interpersonal relationships

Frantic efforts to avoid abandonment

Recurrent suicidal ideation or attempts

Intense anger

Major mood swings
BPD 301.83

Impulsive self destructive or self injurious behavior

Fragile identity or self image

Chronic feelings of emptiness

Transient stress related dissociation or paranoia /9 (5/9)

Self centred or entitled
NPD 301.81

Deceitful, aggressive, or lack of remorse ASP 301.7

COMMENTS:

ADHD=attention deficit hyperactivity disorder; IA=inattentive subtype; HI=hyperactive impulsive subtype; BPD=borderline personality disorder;
NPD=narcissistic personality disorder; ASP=antisocial personality disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Health Disorders, Text Revision (Copyright
2000). American Psychiatric Association.

University of British Columbia 2011. Any part of this document may be freely reproduced without obtaining the permission
of the copyright owner, provided that no changes whatsoever are made to the text and provided that this copyright notice is
included in its entirety in any and all copies of this document.

104 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 5/5
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Weiss Symptom Record (WSR)

Instructions to Informant: Check the box that best # items

describes typical behavior scored 2 or 3
Instructions to Physician: Symptoms rated 2 or 3 Not at all Somewhat Pretty much Very much N/A (DSM
are positive and total count completed below (0) (1) (2) (3) Criteria)

ADHD COMBINED TYPE 314.01

6/9 IA & HI

ATTENTION 314.00

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails

to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted

Forgetful in daily activities /9 (6/9)

HYPERACTIVE/IMPULSIVE 314.01
Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn

Interrupting or intruding on others /9 (6/9)

OPPOSITIONAL DEFIANT DISORDER 313.81

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehaviour

Touchy or easily annoyed by others

Angry or resentful

Spiteful or vindictive
/8 (4/8)

100 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 1/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

TIC DISORDERS 307.2 SEVERITY

Repetitive involuntary movements (blinking, twitching)

Repetitive involuntary noises (throat clearing, sniffing)

CONDUCT DISORDER 312.8

Bullies, threatens, or intimidates others
Initiates physical fights

Has used a weapon (bat, brick, bottle, knife, gun)

Physically cruel to people

Physically cruel to animals

Stolen while confronting a victim

Forced someone into sexual activity

Fire setting with the intent of damage

Deliberately destroyed others' property

Broken into a house, building, or car

Often lies to obtain goods or benefits or avoid obligations

Stealing items of nontrivial value without confronting victim

Stays out at night despite prohibitions

Run away from home overnight at least twice

Truant from school
/15(3/15)
ANXIETY

Worries about health, loved ones, catastrophe 300.02

Unable to relax; nervous
300.81

Chronic unexplained aches and pains
300.30

Repetitive thoughts that make no sense

Repetitive rituals
300.01

Sudden panic attacks with intense anxiety 300.23

Excessively shy

Refusal to do things in front of others 309.21

Refusal to go to school, work or separate from others 300.29

Unreasonable fears that interfere with activities 312.39

Pulls out hair, eyebrows

Nail biting, picking

Refusal to talk in public, but talks at home mutism

DEPRESSION 296.2 (single) .3 (recurrent)

Has been feeling sad, unhappy or depressed Yes No Must be present

No interest or pleasure in life Yes No Must be present
Feels worthless

Has decreased energy and less productive

Hopeless and pessimistic about the future

Excessive feelings of guilt or self blame

Self-injurious or suicidal thoughts

WSR 2/5 101

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEPRESSION (CONT'D) SEVERITY

Social withdrawal

Weight loss or weight gain

5/9>2wks
Change in sleep patterns

Agitated or sluggish, slowed down

Decreased concentration or indecisiveness

Past suicide attempts # Serious

MANIA 296.0(manic) .6(mixes) .5(depressed)

Distinct period of consistent elevated or irritable mood Yes No Must be present

Grandiose, sudden increase in self esteem

Decreased need for sleep

Racing thoughts

Too talkative and speech seems pressured

Sudden increase in goal directed activity, agitated 3 >1wk

High risk activities (spending money, promiscuity) /3 (3)

SOCIAL SKILLS 299

Makes poor eye contact or unusual body language

Failure to make peer relationships

Lack of spontaneous sharing of enjoyment

Lacks reciprocity or sensitivity to emotional needs of others

Language delay or lack of language communication

Difficulty communicating, conversing with others

Speaks in an odd, idiosyncratic or monotonous speech

Lack of creative, imaginative play or social imitation

Intensely fixated on one particular interest

Rigid sticking to nonfunctional routines or rituals

Preoccupied with objects and parts of objects

Repetitive motor mannerisms (hand flapping, spinning)

PSYCHOSIS 295
Has disorganized, illogical thoughts

Hears voices or sees things

Conviction that others are against or will hurt them

People can read their thoughts, or vice versa

Belief that the television is talking specifically to them

A fixed belief that is out of touch with reality

Thought sequence does not make sense

102 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 3/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

SUBSTANCE ABUSE SEVERITY
Excessive alcohol (> 2 drinks/day, > 4 drinks at once) 305
Smokes cigarettes

Daily marijuana use

Use of any other street drugs

Abuse of prescription drugs

SLEEP DISORDERS 307.4

Agitated or sluggish, slowed down
Has difficulty falling asleep

Has difficulty staying asleep

Has abnormal sleep patterns during the day 347

Unanticipated falling asleep during the day 307.4

Sleep walking
307.4

Has nightmares
307.45

Falls asleep late and sleeps in late 3.27

Sleep schedule changes from day to day

Excessive snoring

A feeling of restless legs while trying to sleep

Observed to have sudden kicking while asleep 780.57

Observed to have difficulty breathing at night

ELIMINATION DISORDERS 307

Wets the bed at night

Wets during the day

Soils self
EATING DISORDERS 307

Vomits after meals or binging

Underweight and refuses to eat
307.1

Distorted body image

Picky eater

High junk food diet

LEARNING DISABILITIES 315

Delayed expressive language

Stuttering

Problems articulating words
315

Below grade level in reading
315.1

Below grade level in math
315.2

Trouble with writing (messy, tiring, avoids writing)

Variable performance in school

Underachieves at school relative to potential

315.4

WSR 4/5 103

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEVELOPMENTAL COORDINATION DISORDER

Difficulty with gross motor skills (i.e. gym, sports, biking)

Clumsy

Difficulty with fine motor (buttons, shoe laces, cutting)

PERSONALITY 301 SEVERITY

Unstable interpersonal relationships

Frantic efforts to avoid abandonment

Recurrent suicidal ideation or attempts

Intense anger

Major mood swings
BPD 301.83

Impulsive self destructive or self injurious behavior

Fragile identity or self image

Chronic feelings of emptiness

Transient stress related dissociation or paranoia /9 (5/9)

Self centred or entitled
NPD 301.81

Deceitful, aggressive, or lack of remorse ASP 301.7

COMMENTS:

ADHD=attention deficit hyperactivity disorder; IA=inattentive subtype; HI=hyperactive impulsive subtype; BPD=borderline personality disorder;
NPD=narcissistic personality disorder; ASP=antisocial personality disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Health Disorders, Text Revision (Copyright
2000). American Psychiatric Association.

University of British Columbia 2011. Any part of this document may be freely reproduced without obtaining the permission
of the copyright owner, provided that no changes whatsoever are made to the text and provided that this copyright notice is
included in its entirety in any and all copies of this document.

104 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 5/5
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Weiss Symptom Record (WSR)

Instructions to Informant: Check the box that best # items

describes typical behavior scored 2 or 3
Instructions to Physician: Symptoms rated 2 or 3 Not at all Somewhat Pretty much Very much N/A (DSM
are positive and total count completed below (0) (1) (2) (3) Criteria)

ADHD COMBINED TYPE 314.01

6/9 IA & HI

ATTENTION 314.00

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails

to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted

Forgetful in daily activities /9 (6/9)

HYPERACTIVE/IMPULSIVE 314.01
Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn

Interrupting or intruding on others /9 (6/9)

OPPOSITIONAL DEFIANT DISORDER 313.81

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehaviour

Touchy or easily annoyed by others

Angry or resentful

Spiteful or vindictive
/8 (4/8)

100 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 1/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

TIC DISORDERS 307.2 SEVERITY

Repetitive involuntary movements (blinking, twitching)

Repetitive involuntary noises (throat clearing, sniffing)

CONDUCT DISORDER 312.8

Bullies, threatens, or intimidates others
Initiates physical fights

Has used a weapon (bat, brick, bottle, knife, gun)

Physically cruel to people

Physically cruel to animals

Stolen while confronting a victim

Forced someone into sexual activity

Fire setting with the intent of damage

Deliberately destroyed others' property

Broken into a house, building, or car

Often lies to obtain goods or benefits or avoid obligations

Stealing items of nontrivial value without confronting victim

Stays out at night despite prohibitions

Run away from home overnight at least twice

Truant from school
/15(3/15)
ANXIETY

Worries about health, loved ones, catastrophe 300.02

Unable to relax; nervous
300.81

Chronic unexplained aches and pains
300.30

Repetitive thoughts that make no sense

Repetitive rituals
300.01

Sudden panic attacks with intense anxiety 300.23

Excessively shy

Refusal to do things in front of others 309.21

Refusal to go to school, work or separate from others 300.29

Unreasonable fears that interfere with activities 312.39

Pulls out hair, eyebrows

Nail biting, picking

Refusal to talk in public, but talks at home mutism

DEPRESSION 296.2 (single) .3 (recurrent)

Has been feeling sad, unhappy or depressed Yes No Must be present

No interest or pleasure in life Yes No Must be present
Feels worthless

Has decreased energy and less productive

Hopeless and pessimistic about the future

Excessive feelings of guilt or self blame

Self-injurious or suicidal thoughts

WSR 2/5 101

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEPRESSION (CONT'D) SEVERITY

Social withdrawal

Weight loss or weight gain

5/9>2wks
Change in sleep patterns

Agitated or sluggish, slowed down

Decreased concentration or indecisiveness

Past suicide attempts # Serious

MANIA 296.0(manic) .6(mixes) .5(depressed)

Distinct period of consistent elevated or irritable mood Yes No Must be present

Grandiose, sudden increase in self esteem

Decreased need for sleep

Racing thoughts

Too talkative and speech seems pressured

Sudden increase in goal directed activity, agitated 3 >1wk

High risk activities (spending money, promiscuity) /3 (3)

SOCIAL SKILLS 299

Makes poor eye contact or unusual body language

Failure to make peer relationships

Lack of spontaneous sharing of enjoyment

Lacks reciprocity or sensitivity to emotional needs of others

Language delay or lack of language communication

Difficulty communicating, conversing with others

Speaks in an odd, idiosyncratic or monotonous speech

Lack of creative, imaginative play or social imitation

Intensely fixated on one particular interest

Rigid sticking to nonfunctional routines or rituals

Preoccupied with objects and parts of objects

Repetitive motor mannerisms (hand flapping, spinning)

PSYCHOSIS 295
Has disorganized, illogical thoughts

Hears voices or sees things

Conviction that others are against or will hurt them

People can read their thoughts, or vice versa

Belief that the television is talking specifically to them

A fixed belief that is out of touch with reality

Thought sequence does not make sense

102 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 3/5
 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

SUBSTANCE ABUSE SEVERITY
Excessive alcohol (> 2 drinks/day, > 4 drinks at once) 305
Smokes cigarettes

Daily marijuana use

Use of any other street drugs

Abuse of prescription drugs

SLEEP DISORDERS 307.4

Agitated or sluggish, slowed down
Has difficulty falling asleep

Has difficulty staying asleep

Has abnormal sleep patterns during the day 347

Unanticipated falling asleep during the day 307.4

Sleep walking
307.4

Has nightmares
307.45

Falls asleep late and sleeps in late 3.27

Sleep schedule changes from day to day

Excessive snoring

A feeling of restless legs while trying to sleep

Observed to have sudden kicking while asleep 780.57

Observed to have difficulty breathing at night

ELIMINATION DISORDERS 307

Wets the bed at night

Wets during the day

Soils self
EATING DISORDERS 307

Vomits after meals or binging

Underweight and refuses to eat
307.1

Distorted body image

Picky eater

High junk food diet

LEARNING DISABILITIES 315

Delayed expressive language

Stuttering

Problems articulating words
315

Below grade level in reading
315.1

Below grade level in math
315.2

Trouble with writing (messy, tiring, avoids writing)

Variable performance in school

Underachieves at school relative to potential

315.4

WSR 4/5 103

 Not at all Somewhat Pretty much Very much N/A Diagnoses
(0) (1) (2) (3)

DEVELOPMENTAL COORDINATION DISORDER

Difficulty with gross motor skills (i.e. gym, sports, biking)

Clumsy

Difficulty with fine motor (buttons, shoe laces, cutting)

PERSONALITY 301 SEVERITY

Unstable interpersonal relationships

Frantic efforts to avoid abandonment

Recurrent suicidal ideation or attempts

Intense anger

Major mood swings
BPD 301.83

Impulsive self destructive or self injurious behavior

Fragile identity or self image

Chronic feelings of emptiness

Transient stress related dissociation or paranoia /9 (5/9)

Self centred or entitled
NPD 301.81

Deceitful, aggressive, or lack of remorse ASP 301.7

COMMENTS:

ADHD=attention deficit hyperactivity disorder; IA=inattentive subtype; HI=hyperactive impulsive subtype; BPD=borderline personality disorder;
NPD=narcissistic personality disorder; ASP=antisocial personality disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Health Disorders, Text Revision (Copyright
2000). American Psychiatric Association.

University of British Columbia 2011. Any part of this document may be freely reproduced without obtaining the permission
of the copyright owner, provided that no changes whatsoever are made to the text and provided that this copyright notice is
included in its entirety in any and all copies of this document.

104 Version: July 2012. Refer to www.caddra.ca for latest updates. WSR 5/5
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Weiss Functional Impairment Rating Scale Parent REPORt (WFIRS-P)

Your name: _____________________________________ Relationship to child: ______________________

Circle the number for the rating that best describes how your child's emotional or behavioural problems have
affected each item in the last month.

Never or Sometimes Often or Very often or

not at all or somewhat much very much n/a

A FAMILY

1 Having problems with brothers & sisters 0 1 2 3 n/a

2 Causing problems between parents 0 1 2 3 n/a

3 Takes time away from family members work or activities 0 1 2 3 n/a

4 Causing fighting in the family 0 1 2 3 n/a

5 Isolating the family from friends and social activities 0 1 2 3 n/a

6 Makes it hard for the family to have fun together 0 1 2 3 n/a

7 Makes parenting difficult 0 1 2 3 n/a

8 Makes it hard to give fair attention to all family members 0 1 2 3 n/a

9 Provokes others to hit or scream at him/her 0 1 2 3 n/a

10 Costs the family more money 0 1 2 3 n/a

B SCHOOL

Learning

1 Makes it difficult to keep up with schoolwork 0 1 2 3 n/a

2 Needs extra help at school 0 1 2 3 n/a

3
Needs tutoring 0 1 2 3 n/a

4 Receives grades that are not as good as his/her ability 0 1 2 3 n/a

Behaviour

1 Causes problems for the teacher in the classroom 0 1 2 3 n/a

2 Receives time-out or removal from the classroom 0 1 2 3 n/a

3 Having problems in the school yard 0 1 2 3 n/a

4 Receives detentions (during or after school) 0 1 2 3 n/a

5 Suspended or expelled from school 0 1 2 3 n/a

6 Misses classes or is late for school 0 1 2 3 n/a

C LIFE SKILLS

1 Excessive use of TV, computer, or video games 0 1 2 3 n/a

2 Keeping clean, brushing teeth, brushing hair, bathing, etc. 0 1 2 3 n/a

3 Problems getting ready for school 0 1 2 3 n/a

WFIRS-P 1/2 115
 Never or Sometimes Often or Very often or
not at all or somewhat much very much n/a

4 Problems getting ready for bed 0 1 2 3 n/a

5 Problems with eating (picky eater, junk food) 0 1 2 3 n/a

6 Problems with sleeping 0 1 2 3 n/a

7 Gets hurt or injured 0 1 2 3 n/a

8
Avoids exercise 0 1 2 3 n/a

9 Needs more medical care 0 1 2 3 n/a

10 Has trouble taking medication, getting needles

or visiting the doctor/dentist 0 1 2 3 n/a

D CHILD'S SELF-CONCEPT

1 My child feels bad about himself/herself 0 1 2 3 n/a

2 My child does not have enough fun 0 1 2 3 n/a

3 My child is not happy with his/her life 0 1 2 3 n/a

E SOCIAL ACTIVITIES

1 Being teased or bullied by other children 0 1 2 3 n/a

2 Teases or bullies other children 0 1 2 3 n/a

3 Problems getting along with other children 0 1 2 3 n/a

4 Problems participating in after-school activities (sports, music, clubs) 0 1 2 3 n/a

5 Problems making new friends 0 1 2 3 n/a

6 Problems keeping friends 0 1 2 3 n/a

7 Difficulty with parties (not invited, avoids them, misbehaves) 0 1 2 3 n/a

F RISKY ACTIVITIES

1 Easily led by other children (peer pressure) 0 1 2 3 n/a

2 Breaking or damaging things 0 1 2 3 n/a

3 Doing things that are illegal 0 1 2 3 n/a

4 Being involved with the police 0 1 2 3 n/a

5
Smoking cigarettes 0 1 2 3 n/a

6 Taking illegal drugs 0 1 2 3 n/a

7 Doing dangerous things 0 1 2 3 n/a

8 Causes injury to others 0 1 2 3 n/a

9 Says mean or inappropriate things 0 1 2 3 n/a

10 Sexually inappropriate behaviour 0 1 2 3 n/a

DO NOT WRITE IN THIS AREA

SCORING: A. Family
B. School
1. Number of items scored 2 or 3
or Learning
2. Total score Behaviour
or C. Life skills
3. Mean score
D. Child's self-concept
E. Social activities
F. Risky activities
Total

University of British Columbia 2011. Any part of this document may be freely reproduced without obtaining the permission
of the copyright owner, provided that no changes whatsoever are made to the text and provided that this copyright notice is
included in its entirety in any and all copies of this document
116 Version: July 2012. Refer to www.caddra.ca for latest updates. WFIRS-P 2/2
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Weiss Functional Impairment Rating Scale Parent REPORt (WFIRS-P)

Your name: _____________________________________ Relationship to child: ______________________

Circle the number for the rating that best describes how your child's emotional or behavioural problems have
affected each item in the last month.

Never or Sometimes Often or Very often or

not at all or somewhat much very much n/a

A FAMILY

1 Having problems with brothers & sisters 0 1 2 3 n/a

2 Causing problems between parents 0 1 2 3 n/a

3 Takes time away from family members work or activities 0 1 2 3 n/a

4 Causing fighting in the family 0 1 2 3 n/a

5 Isolating the family from friends and social activities 0 1 2 3 n/a

6 Makes it hard for the family to have fun together 0 1 2 3 n/a

7 Makes parenting difficult 0 1 2 3 n/a

8 Makes it hard to give fair attention to all family members 0 1 2 3 n/a

9 Provokes others to hit or scream at him/her 0 1 2 3 n/a

10 Costs the family more money 0 1 2 3 n/a

B SCHOOL

Learning

1 Makes it difficult to keep up with schoolwork 0 1 2 3 n/a

2 Needs extra help at school 0 1 2 3 n/a

3
Needs tutoring 0 1 2 3 n/a

4 Receives grades that are not as good as his/her ability 0 1 2 3 n/a

Behaviour

1 Causes problems for the teacher in the classroom 0 1 2 3 n/a

2 Receives time-out or removal from the classroom 0 1 2 3 n/a

3 Having problems in the school yard 0 1 2 3 n/a

4 Receives detentions (during or after school) 0 1 2 3 n/a

5 Suspended or expelled from school 0 1 2 3 n/a

6 Misses classes or is late for school 0 1 2 3 n/a

C LIFE SKILLS

1 Excessive use of TV, computer, or video games 0 1 2 3 n/a

2 Keeping clean, brushing teeth, brushing hair, bathing, etc. 0 1 2 3 n/a

3 Problems getting ready for school 0 1 2 3 n/a

WFIRS-P 1/2 115
 Never or Sometimes Often or Very often or
not at all or somewhat much very much n/a

4 Problems getting ready for bed 0 1 2 3 n/a

5 Problems with eating (picky eater, junk food) 0 1 2 3 n/a

6 Problems with sleeping 0 1 2 3 n/a

7 Gets hurt or injured 0 1 2 3 n/a

8
Avoids exercise 0 1 2 3 n/a

9 Needs more medical care 0 1 2 3 n/a

10 Has trouble taking medication, getting needles

or visiting the doctor/dentist 0 1 2 3 n/a

D CHILD'S SELF-CONCEPT

1 My child feels bad about himself/herself 0 1 2 3 n/a

2 My child does not have enough fun 0 1 2 3 n/a

3 My child is not happy with his/her life 0 1 2 3 n/a

E SOCIAL ACTIVITIES

1 Being teased or bullied by other children 0 1 2 3 n/a

2 Teases or bullies other children 0 1 2 3 n/a

3 Problems getting along with other children 0 1 2 3 n/a

4 Problems participating in after-school activities (sports, music, clubs) 0 1 2 3 n/a

5 Problems making new friends 0 1 2 3 n/a

6 Problems keeping friends 0 1 2 3 n/a

7 Difficulty with parties (not invited, avoids them, misbehaves) 0 1 2 3 n/a

F RISKY ACTIVITIES

1 Easily led by other children (peer pressure) 0 1 2 3 n/a

2 Breaking or damaging things 0 1 2 3 n/a

3 Doing things that are illegal 0 1 2 3 n/a

4 Being involved with the police 0 1 2 3 n/a

5
Smoking cigarettes 0 1 2 3 n/a

6 Taking illegal drugs 0 1 2 3 n/a

7 Doing dangerous things 0 1 2 3 n/a

8 Causes injury to others 0 1 2 3 n/a

9 Says mean or inappropriate things 0 1 2 3 n/a

10 Sexually inappropriate behaviour 0 1 2 3 n/a

DO NOT WRITE IN THIS AREA

SCORING: A. Family
B. School
1. Number of items scored 2 or 3
or Learning
2. Total score Behaviour
or C. Life skills
3. Mean score
D. Child's self-concept
E. Social activities
F. Risky activities
Total

University of British Columbia 2011. Any part of this document may be freely reproduced without obtaining the permission
of the copyright owner, provided that no changes whatsoever are made to the text and provided that this copyright notice is
included in its entirety in any and all copies of this document
116 Version: July 2012. Refer to www.caddra.ca for latest updates. WFIRS-P 2/2
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Retrospective assessment of childhood symptoms Current symptoms

ADHD CHECKLIST Current medication:

SYMPTOMS: Check the appropriate box Not at all Somewhat Pretty much Very much Diagnoses
(0) (1) (2) (3)

ATTENTION 314.00 (6/9) SEVERITY TOTAL

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted _/9

Forgetful in daily activities 6/9

HYPERACTIVE/IMPULSIVE 314.01 (6/9)

Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn 6/9

Interrupting or intruding on others _/9

OPPOSITIONAL DEFIANT DISORDER 313.81 (>4/8)

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Touchy or easily annoyed by others

Angry or resentful 4/8

Spiteful or vindictive _/8

COMMENTS

106 Version: July 2012. Refer to www.caddra.ca for latest updates.

 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Retrospective assessment of childhood symptoms Current symptoms

ADHD CHECKLIST Current medication:

SYMPTOMS: Check the appropriate box Not at all Somewhat Pretty much Very much Diagnoses
(0) (1) (2) (3)

ATTENTION 314.00 (6/9) SEVERITY TOTAL

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted _/9

Forgetful in daily activities 6/9

HYPERACTIVE/IMPULSIVE 314.01 (6/9)

Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn 6/9

Interrupting or intruding on others _/9

OPPOSITIONAL DEFIANT DISORDER 313.81 (>4/8)

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Touchy or easily annoyed by others

Angry or resentful 4/8

Spiteful or vindictive _/8

COMMENTS

106 Version: July 2012. Refer to www.caddra.ca for latest updates.

 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

Retrospective assessment of childhood symptoms Current symptoms

ADHD CHECKLIST Current medication:

SYMPTOMS: Check the appropriate box Not at all Somewhat Pretty much Very much Diagnoses
(0) (1) (2) (3)

ATTENTION 314.00 (6/9) SEVERITY TOTAL

Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish work

Difficulting organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted _/9

Forgetful in daily activities 6/9

HYPERACTIVE/IMPULSIVE 314.01 (6/9)

Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn 6/9

Interrupting or intruding on others _/9

OPPOSITIONAL DEFIANT DISORDER 313.81 (>4/8)

Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Touchy or easily annoyed by others

Angry or resentful 4/8

Spiteful or vindictive _/8

COMMENTS

106 Version: July 2012. Refer to www.caddra.ca for latest updates.

 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

SNAP-IV 26 Teacher and Parent Rating Scale

Name: ________________________________________________________ Gender: ___________ Age: ____________

Grade: _______ Ethnicity: African-American Asian Caucasian Hispanic Other: ________________

Completed by: _________________________________________ Type of Class: __________ Class size: _____________

For each item, check the column which best describes this child: Not At All Just A Little Quite A Bit Very Much

1. Often fails to give close attention to details or makes

careless mistakes in schoolwork or tasks

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish

schoolwork, chores, or duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or reluctantly engages in tasks requiring

sustained mental effort

7. Often loses things necessary for activities (e.g., toys,

school assignments, pencils, or books)

8. Often is distracted by extraneous stimuli

9. Often is forgetful in daily activities

10. Often fidgets with hands or feet or squirms in seat

11. Often leaves seat in classroom or in other situations in which

remaining seated is expected

12. Often runs about or climbs excessively in situations in which

it is inappropriate

13. Often has difficulty playing or engaging in leisure activities quietly

14. Often is on the go or often acts as if driven by a motor

15. Often talks excessively

16. Often blurts out answers before questions have been completed

17. Often has difficulty awaiting turn

18. Often interrupts or intrudes on others (e.g. butts into conversations/

games)

19. Often loses temper

20. Often argues with adults

21. Often actively defies or refuses adult requests or rules

22. Often deliberately does things that annoy other people

23. Often blames others for his or her mistakes or misbehavior

24. Often touchy or easily annoyed by others

25. Often is angry and resentful

26. Often is spiteful or vindictive

SNAP-IV-26 1/1 39
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

SNAP-IV 26 Teacher and Parent Rating Scale

Name: ________________________________________________________ Gender: ___________ Age: ____________

Grade: _______ Ethnicity: African-American Asian Caucasian Hispanic Other: ________________

Completed by: _________________________________________ Type of Class: __________ Class size: _____________

For each item, check the column which best describes this child: Not At All Just A Little Quite A Bit Very Much

1. Often fails to give close attention to details or makes

careless mistakes in schoolwork or tasks

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish

schoolwork, chores, or duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or reluctantly engages in tasks requiring

sustained mental effort

7. Often loses things necessary for activities (e.g., toys,

school assignments, pencils, or books)

8. Often is distracted by extraneous stimuli

9. Often is forgetful in daily activities

10. Often fidgets with hands or feet or squirms in seat

11. Often leaves seat in classroom or in other situations in which

remaining seated is expected

12. Often runs about or climbs excessively in situations in which

it is inappropriate

13. Often has difficulty playing or engaging in leisure activities quietly

14. Often is on the go or often acts as if driven by a motor

15. Often talks excessively

16. Often blurts out answers before questions have been completed

17. Often has difficulty awaiting turn

18. Often interrupts or intrudes on others (e.g. butts into conversations/

games)

19. Often loses temper

20. Often argues with adults

21. Often actively defies or refuses adult requests or rules

22. Often deliberately does things that annoy other people

23. Often blames others for his or her mistakes or misbehavior

24. Often touchy or easily annoyed by others

25. Often is angry and resentful

26. Often is spiteful or vindictive

SNAP-IV-26 1/1 39
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

SNAP-IV 26 Teacher and Parent Rating Scale

Name: ________________________________________________________ Gender: ___________ Age: ____________

Grade: _______ Ethnicity: African-American Asian Caucasian Hispanic Other: ________________

Completed by: _________________________________________ Type of Class: __________ Class size: _____________

For each item, check the column which best describes this child: Not At All Just A Little Quite A Bit Very Much

1. Often fails to give close attention to details or makes

careless mistakes in schoolwork or tasks

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish

schoolwork, chores, or duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or reluctantly engages in tasks requiring

sustained mental effort

7. Often loses things necessary for activities (e.g., toys,

school assignments, pencils, or books)

8. Often is distracted by extraneous stimuli

9. Often is forgetful in daily activities

10. Often fidgets with hands or feet or squirms in seat

11. Often leaves seat in classroom or in other situations in which

remaining seated is expected

12. Often runs about or climbs excessively in situations in which

it is inappropriate

13. Often has difficulty playing or engaging in leisure activities quietly

14. Often is on the go or often acts as if driven by a motor

15. Often talks excessively

16. Often blurts out answers before questions have been completed

17. Often has difficulty awaiting turn

18. Often interrupts or intrudes on others (e.g. butts into conversations/

games)

19. Often loses temper

20. Often argues with adults

21. Often actively defies or refuses adult requests or rules

22. Often deliberately does things that annoy other people

23. Often blames others for his or her mistakes or misbehavior

24. Often touchy or easily annoyed by others

25. Often is angry and resentful

26. Often is spiteful or vindictive

SNAP-IV-26 1/1 39
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

CADDRA Teacher Assessment Form

Adapted from Dr Rosemary Tannock's Teacher Telephone Interview.
Reprinted for clinical use only with permission from the BC Provincial ADHD Program.

Student's Name: Age: Sex:

School: Grade:

Educator completing this form: ____________________________________ Date completed: ______________________

How long have you known the student? _________________ Time spent each day with student: ___________________

Student's Placement: ___________________________________ Special Ed: Yes No Hrs per week: __________

Student's Educational Designation: ___________________________________________________________ None

Does this student have an educational plan?: Yes No

Well Below Somewhat Below At Grade Somewhat Above Well Above

ACADEMIC PERFORMANCE Grade Level Grade Level Level Grade Level Grade Level n/a

READING

a) Decoding

b) Comprehension

c) Fluency

WRITING

d) Handwriting

e) Spelling

f) Written syntax (sentence level)

g) Written composition (text level)

MATHEMATICS

h) Computation (accuracy)

i) Computation (fluency)

j) Applied mathematical reasoning

Well Below Well Above

CLASSROOM PERFORMANCE Average Below Average Average Above Average Average n/a

Following directions/instructions

Organizational skills

Assignment completion

Peer relationships

Classroom Behaviour

CADDRA TEACHER ASSESSMENT FORM 1/3 117

 CADDRA Teacher Assessment Form
Strengths: What are this student's strengths? ___________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Education plan: If this student has an education plan, what are the recommendations? Do they work? ______________
_____________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________________________

Accommodations: What accommodations are in place? Are they effective? ___________________________________

______________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________________

Class Instructions: How well does this student handle large-group instruction? Does s/he follow instructions well? Can
s/he wait for a turn to respond? Would s/he stand out from same-sex peers? In what way? ________________________
_______________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________

Individual seat work: How well does this student self-regulate attention and behaviour during assignments to be com-
pleted as individual seat work? Is the work generally completed? Would s/he stand out from same-sex peers?
In what way? _______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Transitions: How does this student handle transitions such as going in and out for recess, changing classes or changing
activities? Doe s/he follow routines well? What amount of supervision or reminders does s/he need? ________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Impact on peer relations: How does this student get along with others? Does this student have friends that seek him/
her out? Does s/he initiate play successfully? ___________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________________________________________
____________________________________________________________________________________________

Conflict and Aggression: Is s/he often in conflict with adults or peers? How does s/he resolve arguments? Is the
student verbally or physically aggressive? Is s/he the target of verbal or physical aggression by peers? _____________
_________________________________________________________________________________________________
______________________________________________________________________________________________
____________________________________________________________________________________________

Academic Abilities: We would like to know about this student's general abilities and academic skills. Does this student
appear to learn at a similar rate to others? Does this student appear to have specific weaknesses in learning?
________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Self-help skills, independence, problem solving, activities of daily living: ______________________________________

________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

118 Version: July 2012. Refer to www.caddra.ca for latest updates. CADDRA TEACHER ASSESSMENT FORM 2/3
Motor Skills (gross/fine): Does this student have problems with gym, sports, writing? If so, please describe.
________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________________________________________________

Written output: Does this student have problems putting ideas down in writing? If so, please describe.
________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________________________________________________

Primary Areas of concern: What are your major areas of concern/worry for this student? How long has this/these been
a concern for you? __________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________

Impact on student: To what extent are these difficulties for the student upsetting or distressing to the student him/
herself, to you and/or the other students? _______________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________

Impact on the class: Does this student make it difficult for you to teach the class? _____________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Medications: If this student is on medication, is there anything you would like to highlight about the differences when
s/he is on medication compared to off? __________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Parent involvement: What has been the involvement of the parent(s)? _______________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Are the problems with attention and/or hyperactivity interfering with the student's learning? Peer relationships? ______
__________________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________________________________________

Has the student had any particular problems with homework or handing in assignments? __________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

Is there anything else you would like us to know? If you feel the need to contact the student's clinician
during this assessment please feel free to do so. ______________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

CADDRA TEACHER ASSESSMENT FORM 3/3 119

 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

CADDRA PATIENT ADHD MEDICATION FORM

Please complete and bring to your next appointment

Patient name: _____________________________________________ Date form is completed: ____________________

Person completing this form (if not the patient): ________________________________ Mother Father Other

Medication usage since (decided with doctor): Current Medication List:

________________________________(date) _______________________________________________
Medication not started yet _______________________________________________
Takes medication regularly, as prescribed _______________________________________________
Forgets/skips doses occasionally _______________________________________________
Takes medication irregularly _______________________________________________
Medication stopped _______________________________________________

Instructions to use the quadrant below:

1. Place a mark on the horizontal black line indicating the level of current symptom control between -3 and +3.
2. Place a mark on the vertical black line indicating current side effect levels, between -3 to +3
3. Draw an X where lines from the marks made on each line would meet to show current patient status

NO SIDE EFFECTS - GOOD QUALITY OF LIFE

COMMENTS:
_________________________________
+
_________________________________
+3
_________________________________
+2
_________________________________
+1 _________________________________
_________________________________
-3 -2 -1 +1 +2 +3
Poor - + Good
_________________________________
control control
_________________________________
-1
_________________________________
-2
_________________________________
-3 _________________________________
- _________________________________

SIDE EFFECTS WITH IMPACT ON QUALITY OF LIFE

_________________________________

What changes have occurred since medication started?

Not applicable: no medication taken No change Marked Improvement

Small deterioration Improvement Deterioration
Small improvement Marked deterioration
CADDRA PATIENT ADHD MEDICATION FORM 1/2 121
 Please indicate below the frequency of any side effects experienced since the last medical appointment
(mark with an X). Please contact your physician if side effects are significant.

SIDE EFFECT FREQUENCY

Not at all Sometimes Often All the time Comments

Headache

Dryness of the skin

Dryness of the eyes

Dryness of the mouth

Thirst

Sore throat

Dizziness

Nausea

Stomach aches

Vomiting

Sweating

Appetite reduction

Weight loss

Weight gain

Diarrhea

Frequent urination

Tics

Sleep difficulties

Mood instability

Irritability

Agitation/excitability

Sadness

Heart palpitations

Increased blood pressure

Sexual dysfunction

Feeling worse or different when

the medication wears off (rebound)

Other:

Things to discuss at the next medical appointment:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

122 Version: July 2012. Refer to www.caddra.ca for latest updates. CADDRA PATIENT ADHD MEDICATION FORM 2/2
 Patient Name:
Date of Birth: MRN/File No:
Physician Name: Date:

CADDRA PATIENT ADHD MEDICATION FORM

Please complete and bring to your next appointment

Patient name: _____________________________________________ Date form is completed: ____________________

Person completing this form (if not the patient): ________________________________ Mother Father Other

Medication usage since (decided with doctor): Current Medication List:

________________________________(date) _______________________________________________
Medication not started yet _______________________________________________
Takes medication regularly, as prescribed _______________________________________________
Forgets/skips doses occasionally _______________________________________________
Takes medication irregularly _______________________________________________
Medication stopped _______________________________________________

Instructions to use the quadrant below:

1. Place a mark on the horizontal black line indicating the level of current symptom control between -3 and +3.
2. Place a mark on the vertical black line indicating current side effect levels, between -3 to +3
3. Draw an X where lines from the marks made on each line would meet to show current patient status

NO SIDE EFFECTS - GOOD QUALITY OF LIFE

COMMENTS:
_________________________________
+
_________________________________
+3
_________________________________
+2
_________________________________
+1 _________________________________
_________________________________
-3 -2 -1 +1 +2 +3
Poor - + Good
_________________________________
control control
_________________________________
-1
_________________________________
-2
_________________________________
-3 _________________________________
- _________________________________

SIDE EFFECTS WITH IMPACT ON QUALITY OF LIFE

_________________________________

What changes have occurred since medication started?

Not applicable: no medication taken No change Marked Improvement

Small deterioration Improvement Deterioration
Small improvement Marked deterioration
CADDRA PATIENT ADHD MEDICATION FORM 1/2 121
 Please indicate below the frequency of any side effects experienced since the last medical appointment
(mark with an X). Please contact your physician if side effects are significant.

SIDE EFFECT FREQUENCY

Not at all Sometimes Often All the time Comments

Headache

Dryness of the skin

Dryness of the eyes

Dryness of the mouth

Thirst

Sore throat

Dizziness

Nausea

Stomach aches

Vomiting

Sweating

Appetite reduction

Weight loss

Weight gain

Diarrhea

Frequent urination

Tics

Sleep difficulties

Mood instability

Irritability

Agitation/excitability

Sadness

Heart palpitations

Increased blood pressure

Sexual dysfunction

Feeling worse or different when

the medication wears off (rebound)

Other:

Things to discuss at the next medical appointment:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

122 Version: July 2012. Refer to www.caddra.ca for latest updates. CADDRA PATIENT ADHD MEDICATION FORM 2/2