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Home Behavior Questionnaire

Child's Name:
Parent's Name:
Child's Sex:
Child's Age:
Date: (mm/dd/yyyy)
Time Of Day:
Listed below are some observation statements about children's behaviors. Read each item carefully, then describe how much you think your child has displayed these behaviors by marking appropriate column. Please confine your observation to the past two weeks and answer all items. Press the Submit button when you have completed the form.
  Observation Statements Not at All Just a Little Quite a Bit Very Much
1: Excitable, impulsive, doesn't think before acting
2: Cries easily or often
3: Restless in the "squirmy" sense, unable to sit still
4: Restless, always on the go, unable to remain in his/her seat
5: Destructive, disrespectful of property of others
6: Fails to finish things, tries to do more than one thing at a time
7: Distractable, short attention span, bothered by outside noises
8: Mood changes quickly, dramatically and unpredictably
9: Easily frustrated in efforts
10: Disturbs other children
11: Frequently stares into space or looks out window
12: Impatient with others, tries to hurry others
13: Please provide any additional information which you think is important about your child's behavior:


Omar Rieche, MD, PA
1705 Colonial Blvd. Suite B1, Fort Myers, FL • Phone: 239.278.7788 • Email:

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