Consumable Booklet
OLOGICAL of
AGRA
T. M. Regd. No. 564838
ADHD-BR
Copyright Regd. No. © A-73256/2005 Dt. 13.5.05
(Evaluation Form)
Dr. Rajshree Bhargava (Agra) (English Version)
Please fillin the following information either by Mother/Father/Teacher/Any other :
Name of the Child_
Father's Name.
Date of Birth Sex : Male Female
Class School.
Address
Mobile Date
Instructions
This form is meant toassess the behaviour of your child, we request you to
give the correct response which you feel of your ward or student of each
statement. The response will be kept confidential, each statement has three
alternative responses like this:
Sometimes Never
Always
You have to tick Mlany one of the above responses applicable on your child.
(Signature of Parents) (Name of Expert)
Estd. 1971 [Link] :(0562) 2601080
NATIONAL PSYCHOLOGICAL CORPORATION
UG-1, Nirmal Heights, Near Mental Hospital, Agra-282 007
2| Consumable Booklet of ADHD-BR Evaluation Form
Response Alternatives
[Link]. STATEMENTS Always Sometimes Never
PART I-Attention Deficit or Inattention
1. Finds difficulty in understanding
details and following instructions.
2. When told to do something, he / she
does not listen attentively.
3. Lack of concentration in doing any
task.
4. Makes careless mistakes in doing
homework or any assigned
responsibilities.
5. Feels hardship indoing any work that
require sus-tained mental efforts
whether at school or at home.
6. Forgets to keep or loses the required
materials like books, notebooks, pen
pencil or colours.
7. Inattentive to do daily routine
activities or responsibilities.
8. Easilydistracted by external stimuli
like T.V. or involvements with peers.
9. Feels difficulty in organizing any task
or activity.
[Link] leaves the given work/activity
incomplete.
Total Score Part I
Consumable Booklet of ADHD-BR Evaluation Form 3
Response Alternatives
[Link]. STATEMENTS Always | Sometimes Never
PART II-Hyper Activity
1, Feels discomfort (squirm) in seat and
fidgets with hands or feet.
2. Feels difficulty to sit stably on a
particular place.
3. Inappropriately runs and climbs from
here and there.
4. Uncomfortable in engaging himself in
leisure time activities.
5. Occasionally ready to go anywhere
without thinking consequences.
6. Talks excessively without any
necessity.
Total Score Part II
PART III-Impulsivity
7. Talks before listening completely to
others.
8. Mostly indisciplined in almost all
situations.
9. Often disturbs and interrupts other's
works.
10. Often makes many errors on an
assignment in an effort to finish
quickly.
Total Score Part III
4 Gonsumable Booklet of ADHD-BP Evaluation Form
Predominantly
Inattention Hyper Activity + Impulsivity
Raw Seore
Interpretation
Total Scors I+Il 4 11
Interpretation of ADHD
Note : Please observe whether child is having
(i) Speech defects like stuttering, stammaring.
(ii) Bed Wetting.
(ii) I. Q.
(iv) Mental Level.
() Learning Disability.
Scorer