Impireum Assessment Scale -Parent Informant Impireum Assessment Scale -Parent InformantToday’s Date:(Required) MM slash DD slash YYYY Child’s Name:(Required) First Date of Birth:(Required) MM slash DD slash YYYY Parent’s Name:(Required)Parent’s Phone Number:(Required)Email(Required) Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.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 Often19. Argues with adults(Required) Never Occasionally Often Very Often20. Loses temper(Required) Never Occasionally Often Very Often21. Actively defies or refuses to go along with adults’ requests or rules(Required) Never Occasionally Often Very Often22. Deliberately annoys people(Required) Never Occasionally Often Very Often23. Blames others for his or her mistakes or misbehaviors(Required) Never Occasionally Often Very Often24. Is touchy or easily annoyed by others(Required) Never Occasionally Often Very Often25. Is angry or resentful(Required) Never Occasionally Often Very Often26. Is spiteful and wants to get even(Required) Never Occasionally Often Very Often27. Bullies, threatens, or intimidates others(Required) Never Occasionally Often Very Often28. Starts physical fights(Required) Never Occasionally Often Very Often29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)(Required) Never Occasionally Often Very Often30. Is truant from school (skips school) without permission(Required) Never Occasionally Often Very Often31. Is physically cruel to people(Required) Never Occasionally Often Very Often32. Has stolen things that have value(Required) Never Occasionally Often Very Often33. Deliberately destroys others’ property(Required) Never Occasionally Often Very Often34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)(Required) Never Occasionally Often Very Often35. Is physically cruel to animals(Required) Never Occasionally Often Very Often36. Has deliberately set fires to cause damage(Required) Never Occasionally Often Very Often37. Has broken into someone else’s home, business, or car(Required) Never Occasionally Often Very Often38. Has stayed out at night without permission(Required) Never Occasionally Often Very Often39. Has run away from home overnight(Required) Never Occasionally Often Very Often40. Has forced someone into sexual activity(Required) Never Occasionally Often Very Often41. Is fearful, anxious, or worried(Required) Never Occasionally Often Very Often42. Is afraid to try new things for fear of making mistakes(Required) Never Occasionally Often Very Often43. Feels worthless or inferior(Required) Never Occasionally Often Very Often44. Blames self for problems, feels guilty(Required) Never Occasionally Often Very Often45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”(Required) Never Occasionally Often Very Often46. Is sad, unhappy, or depressed(Required) Never Occasionally Often Very Often47. Is self-conscious or easily embarrassed(Required) Never Occasionally Often Very OftenPerformance48. Overall school performance(Required) Excellent Above Average Average Somewhat of a Problem Problematic49. Reading(Required) Excellent Above Average Average Somewhat of a Problem Problematic50. Writing(Required) Excellent Above Average Average Somewhat of a Problem Problematic51. Mathematics(Required) Excellent Above Average Average Somewhat of a Problem Problematic52. Relationship with parents(Required) Excellent Above Average Average Somewhat of a Problem Problematic53. Relationship with siblings(Required) Excellent Above Average Average Somewhat of a Problem Problematic54. Relationship with peers(Required) Excellent Above Average Average Somewhat of a Problem Problematic55. Participation in organized activities (eg, teams)(Required) Excellent Above Average Average Somewhat of a Problem Problematic
