Impireum Assessment Follow-up—TEACHER Informant Impireum Assessment Followup—TEACHER InformantTeacher’s Name:(Required)Class Time:(Required) Hours: Minutes AMPM AM/PMClass Name/Period:(Required)Today’s Date:(Required) MM slash DD slash YYYY Child’s Name:(Required)Grade Level:(Required)Email(Required) Directions: 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 last assessment scale was filled out. Please indicate the number of weeks or months you have been able to evaluate the behaviors.Is this evaluation based on a time when the child(Required) was on medication was not on medication not sure?Symptoms1. Does not pay attention to details or makes careless mistakes with, for example, homework(Required) Never Occasionally Often Very Often2. Has difficulty keeping attention to what needs to be done(Required) Never Occasionally Often Very Often3. Does not seem to listen when spoken to directly(Required) Never Occasionally Often Very Often4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)(Required) Never Occasionally Often Very Often5. Has difficulty organizing tasks and activities(Required) Never Occasionally Often Very Often6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort(Required) Never Occasionally Often Very Often7. Loses things necessary for tasks or activities (toys, assignments, pencils,or books)(Required) Never Occasionally Often Very Often8. Is easily distracted by noises or other stimuli(Required) Never Occasionally Often Very Often9. Is forgetful in daily activities(Required) Never Occasionally Often Very Often10. Fidgets with hands or feet or squirms in seat(Required) Never Occasionally Often Very Often11. Leaves seat when remaining seated is expected(Required) Never Occasionally Often Very Often12. Runs about or climbs too much when remaining seated is expected(Required) Never Occasionally Often Very Often13. Has difficulty playing or beginning quiet play activities(Required) Never Occasionally Often Very Often14. Is “on the go” or often acts as if “driven by a motor”(Required) Never Occasionally Often Very Often15. Talks too much(Required) Never Occasionally Often Very Often16. Blurts out answers before questions have been completed(Required) Never Occasionally Often Very Often17. Has difficulty waiting his or her turn(Required) Never Occasionally Often Very Often18. Interrupts or intrudes in on others’ conversations and/or activities(Required) Never Occasionally Often Very OftenPerformance19. Reading(Required) Excellent Above Average Average Somewhat of a Problem Problematic20. Mathematics(Required) Excellent Above Average Average Somewhat of a Problem Problematic21. Written expression(Required) Excellent Above Average Average Somewhat of a Problem Problematic22. Relationship with peers(Required) Excellent Above Average Average Somewhat of a Problem Problematic23. Following direction(Required) Excellent Above Average Average Somewhat of a Problem Problematic24. Disrupting class(Required) Excellent Above Average Average Somewhat of a Problem Problematic25. Assignment completion(Required) Excellent Above Average Average Somewhat of a Problem Problematic26. Organizational skills(Required) Excellent Above Average Average Somewhat of a Problem ProblematicSide Effects: Has your child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem?Headache(Required) None Mild Moderate SevereStomachache(Required) None Mild Moderate SevereChange of appetite—explain below(Required) None Mild Moderate SevereTrouble sleeping(Required) None Mild Moderate SevereIrritability in the late morning, late afternoon, or evening—explain below(Required) None Mild Moderate SevereSocially withdrawn—decreased interaction with others(Required) None Mild Moderate SevereExtreme sadness or unusual crying(Required) None Mild Moderate SevereDull, tired, listless behavior(Required) None Mild Moderate SevereTremors/feeling shaky(Required) None Mild Moderate SevereRepetitive movements, tics, jerking, twitching, eye blinking—explain below(Required) None Mild Moderate SeverePicking at skin or fingers, nail biting, lip or cheek chewing—explain below(Required) None Mild Moderate SevereSees or hears things that aren’t there(Required) None Mild Moderate SevereExplain/Comments:(Required)
