BI-COUNTY PEDIATRICS, P.C.

Raymond P. Flowers, D.O., FAAP, FACOP

Andrea C. Goings, M.D., FAAP        

Telephone: 770-949-3888    Fax: 770-949-3504

CLASSROOM FOLLOW-UP EVALUATION

Name of student________________________________________Grade____________

Teacher_______________________________Date of evaluation__________________

                                                                                    Magnitude of Problem

                                                                           None      Mild      Moderate      Severe

1)  Task Completion                                           ____      ____         ____            ____

2)  Concentration                                                ____      ____         ____            ____

3)  Disruption of Class                                       ____      ____         ____            ____

4)  Impulsivity                                                   ____      ____          ____            ____

5)  Homework Completion                               ____      ____          ____            ____

6)  Difficulty Learning                                      ____      ____          ____            ____

7)  Distractibility                                               ____      ____          ____            ____

8)  Peer Relationships                                       ____      ____          ____             ____

Time of Class_____________

Grades:

Teacher Comments: