PGA pedsPCF Parent Report

ID#:

Please circle the one choice for each statement below that tells how frequent (true) the statement is for your child in the past two weeks.

Space Cell	None of the time	A little of the time	Some of the time	Most of the time	All of the time	Not Applicable
1. It is hard for your child to find his/her way to a place that he/she has visited several times before.	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: None of the time	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: A little of the time	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: Some of the time	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: Most of the time	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: All of the time	1. It is hard for your child to find his/her way to a place that he/she has visited several times before.: Not Applicable
2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: None of the time	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: A little of the time	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: Some of the time	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: Most of the time	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: All of the time	2. Your child has trouble remembering where he/she put things, like his/her watch or his/her homework.: Not Applicable
3. Your child has trouble remembering the names of people he/she has just met.	3. Your child has trouble remembering the names of people he/she has just met.: None of the time	3. Your child has trouble remembering the names of people he/she has just met.: A little of the time	3. Your child has trouble remembering the names of people he/she has just met.: Some of the time	3. Your child has trouble remembering the names of people he/she has just met.: Most of the time	3. Your child has trouble remembering the names of people he/she has just met.: All of the time	3. Your child has trouble remembering the names of people he/she has just met.: Not Applicable
4. Your child is able to keep his/her mind on things like homework or reading.	4. Your child is able to keep his/her mind on things like homework or reading.: None of the time	4. Your child is able to keep his/her mind on things like homework or reading.: A little of the time	4. Your child is able to keep his/her mind on things like homework or reading.: Some of the time	4. Your child is able to keep his/her mind on things like homework or reading.: Most of the time	4. Your child is able to keep his/her mind on things like homework or reading.: All of the time	4. Your child is able to keep his/her mind on things like homework or reading.: Not Applicable
5. It is hard for your child to take notes in class.	5. It is hard for your child to take notes in class.: None of the time	5. It is hard for your child to take notes in class.: A little of the time	5. It is hard for your child to take notes in class.: Some of the time	5. It is hard for your child to take notes in class.: Most of the time	5. It is hard for your child to take notes in class.: All of the time	5. It is hard for your child to take notes in class.: Not Applicable
6. It is hard for your child to learn new things.	6. It is hard for your child to learn new things.: None of the time	6. It is hard for your child to learn new things.: A little of the time	6. It is hard for your child to learn new things.: Some of the time	6. It is hard for your child to learn new things.: Most of the time	6. It is hard for your child to learn new things.: All of the time	6. It is hard for your child to learn new things.: Not Applicable
7. It is hard for your child to understand pictures that show how to make something.	7. It is hard for your child to understand pictures that show how to make something.: None of the time	7. It is hard for your child to understand pictures that show how to make something.: A little of the time	7. It is hard for your child to understand pictures that show how to make something.: Some of the time	7. It is hard for your child to understand pictures that show how to make something.: Most of the time	7. It is hard for your child to understand pictures that show how to make something.: All of the time	7. It is hard for your child to understand pictures that show how to make something.: Not Applicable
8. It is hard for your child to pay attention to something boring he/she has to do.	8. It is hard for your child to pay attention to something boring he/she has to do.: None of the time	8. It is hard for your child to pay attention to something boring he/she has to do.: A little of the time	8. It is hard for your child to pay attention to something boring he/she has to do.: Some of the time	8. It is hard for your child to pay attention to something boring he/she has to do.: Most of the time	8. It is hard for your child to pay attention to something boring he/she has to do.: All of the time	8. It is hard for your child to pay attention to something boring he/she has to do.: Not Applicable
9. It is hard for your child to pay attention to one thing for more than 5–10 min.	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: None of the time	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: A little of the time	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: Some of the time	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: Most of the time	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: All of the time	9. It is hard for your child to pay attention to one thing for more than 5–10 min.: Not Applicable
10. Your child has trouble recalling the names of things.	10. Your child has trouble recalling the names of things.: None of the time	10. Your child has trouble recalling the names of things.: A little of the time	10. Your child has trouble recalling the names of things.: Some of the time	10. Your child has trouble recalling the names of things.: Most of the time	10. Your child has trouble recalling the names of things.: All of the time	10. Your child has trouble recalling the names of things.: Not Applicable
11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: None of the time	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: A little of the time	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: Some of the time	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: Most of the time	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: All of the time	11. Your child has trouble keeping track of what he/she is doing if he/she gets interrupted.: Not Applicable
12. It is hard for your child to do more than one thing at a time.	12. It is hard for your child to do more than one thing at a time.: None of the time	12. It is hard for your child to do more than one thing at a time.: A little of the time	12. It is hard for your child to do more than one thing at a time.: Some of the time	12. It is hard for your child to do more than one thing at a time.: Most of the time	12. It is hard for your child to do more than one thing at a time.: All of the time	12. It is hard for your child to do more than one thing at a time.: Not Applicable
13. Your child forgets what his/her parents or teachers ask him/her to do.	13. Your child forgets what his/her parents or teachers ask him/her to do.: None of the time	13. Your child forgets what his/her parents or teachers ask him/her to do.: A little of the time	13. Your child forgets what his/her parents or teachers ask him/her to do.: Some of the time	13. Your child forgets what his/her parents or teachers ask him/her to do.: Most of the time	13. Your child forgets what his/her parents or teachers ask him/her to do.: All of the time	13. Your child forgets what his/her parents or teachers ask him/her to do.: Not Applicable
14. Your child walks into a room and forgets what he/she wanted to get or do.	14. Your child walks into a room and forgets what he/she wanted to get or do.: None of the time	14. Your child walks into a room and forgets what he/she wanted to get or do.: A little of the time	14. Your child walks into a room and forgets what he/she wanted to get or do.: Some of the time	14. Your child walks into a room and forgets what he/she wanted to get or do.: Most of the time	14. Your child walks into a room and forgets what he/she wanted to get or do.: All of the time	14. Your child walks into a room and forgets what he/she wanted to get or do.: Not Applicable
15. Your child has trouble remembering the names of people he/she knows.	15. Your child has trouble remembering the names of people he/she knows.: None of the time	15. Your child has trouble remembering the names of people he/she knows.: A little of the time	15. Your child has trouble remembering the names of people he/she knows.: Some of the time	15. Your child has trouble remembering the names of people he/she knows.: Most of the time	15. Your child has trouble remembering the names of people he/she knows.: All of the time	15. Your child has trouble remembering the names of people he/she knows.: Not Applicable
16. It is hard for your child to add or subtract numbers in his/her head.	16. It is hard for your child to add or subtract numbers in his/her head.: None of the time	16. It is hard for your child to add or subtract numbers in his/her head.: A little of the time	16. It is hard for your child to add or subtract numbers in his/her head.: Some of the time	16. It is hard for your child to add or subtract numbers in his/her head.: Most of the time	16. It is hard for your child to add or subtract numbers in his/her head.: All of the time	16. It is hard for your child to add or subtract numbers in his/her head.: Not Applicable
17. Your child has trouble remembering the date or day of the week.	17. Your child has trouble remembering the date or day of the week.: None of the time	17. Your child has trouble remembering the date or day of the week.: A little of the time	17. Your child has trouble remembering the date or day of the week.: Some of the time	17. Your child has trouble remembering the date or day of the week.: Most of the time	17. Your child has trouble remembering the date or day of the week.: All of the time	17. Your child has trouble remembering the date or day of the week.: Not Applicable
18. When your child has a big project to do, he/she has trouble deciding where to start.	18. When your child has a big project to do, he/she has trouble deciding where to start.: None of the time	18. When your child has a big project to do, he/she has trouble deciding where to start.: A little of the time	18. When your child has a big project to do, he/she has trouble deciding where to start.: Some of the time	18. When your child has a big project to do, he/she has trouble deciding where to start.: Most of the time	18. When your child has a big project to do, he/she has trouble deciding where to start.: All of the time	18. When your child has a big project to do, he/she has trouble deciding where to start.: Not Applicable
19. Your child has to contact his/her friends for homework he/she forgot.	19. Your child has to contact his/her friends for homework he/she forgot.: None of the time	19. Your child has to contact his/her friends for homework he/she forgot.: A little of the time	19. Your child has to contact his/her friends for homework he/she forgot.: Some of the time	19. Your child has to contact his/her friends for homework he/she forgot.: Most of the time	19. Your child has to contact his/her friends for homework he/she forgot.: All of the time	19. Your child has to contact his/her friends for homework he/she forgot.: Not Applicable
20. Your child has a hard time keeping track of his/her homework.	20. Your child has a hard time keeping track of his/her homework.: None of the time	20. Your child has a hard time keeping track of his/her homework.: A little of the time	20. Your child has a hard time keeping track of his/her homework.: Some of the time	20. Your child has a hard time keeping track of his/her homework.: Most of the time	20. Your child has a hard time keeping track of his/her homework.: All of the time	20. Your child has a hard time keeping track of his/her homework.: Not Applicable
21. Your child forgets to bring things to and from school that he/she needs for homework.	21. Your child forgets to bring things to and from school that he/she needs for homework.: None of the time	21. Your child forgets to bring things to and from school that he/she needs for homework.: A little of the time	21. Your child forgets to bring things to and from school that he/she needs for homework.: Some of the time	21. Your child forgets to bring things to and from school that he/she needs for homework.: Most of the time	21. Your child forgets to bring things to and from school that he/she needs for homework.: All of the time	21. Your child forgets to bring things to and from school that he/she needs for homework.: Not Applicable
22. Your child forgets what he/she is going to say.	22. Your child forgets what he/she is going to say.: None of the time	22. Your child forgets what he/she is going to say.: A little of the time	22. Your child forgets what he/she is going to say.: Some of the time	22. Your child forgets what he/she is going to say.: Most of the time	22. Your child forgets what he/she is going to say.: All of the time	22. Your child forgets what he/she is going to say.: Not Applicable
23. Your child has to read things several times to understand them.	23. Your child has to read things several times to understand them.: None of the time	23. Your child has to read things several times to understand them.: A little of the time	23. Your child has to read things several times to understand them.: Some of the time	23. Your child has to read things several times to understand them.: Most of the time	23. Your child has to read things several times to understand them.: All of the time	23. Your child has to read things several times to understand them.: Not Applicable
24. Your child reacts slower than most people his/her age when he/she plays games.	24. Your child reacts slower than most people his/her age when he/she plays games.: None of the time	24. Your child reacts slower than most people his/her age when he/she plays games.: A little of the time	24. Your child reacts slower than most people his/her age when he/she plays games.: Some of the time	24. Your child reacts slower than most people his/her age when he/she plays games.: Most of the time	24. Your child reacts slower than most people his/her age when he/she plays games.: All of the time	24. Your child reacts slower than most people his/her age when he/she plays games.: Not Applicable
25. It is hard for your child to find the right words to say what he/she means.	25. It is hard for your child to find the right words to say what he/she means.: None of the time	25. It is hard for your child to find the right words to say what he/she means.: A little of the time	25. It is hard for your child to find the right words to say what he/she means.: Some of the time	25. It is hard for your child to find the right words to say what he/she means.: Most of the time	25. It is hard for your child to find the right words to say what he/she means.: All of the time	25. It is hard for your child to find the right words to say what he/she means.: Not Applicable
26. It takes your child longer than other people to get his/her school work done.	26. It takes your child longer than other people to get his/her school work done.: None of the time	26. It takes your child longer than other people to get his/her school work done.: A little of the time	26. It takes your child longer than other people to get his/her school work done.: Some of the time	26. It takes your child longer than other people to get his/her school work done.: Most of the time	26. It takes your child longer than other people to get his/her school work done.: All of the time	26. It takes your child longer than other people to get his/her school work done.: Not Applicable
27. Your child forgets things easily.	27. Your child forgets things easily.: None of the time	27. Your child forgets things easily.: A little of the time	27. Your child forgets things easily.: Some of the time	27. Your child forgets things easily.: Most of the time	27. Your child forgets things easily.: All of the time	27. Your child forgets things easily.: Not Applicable
28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: None of the time	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: A little of the time	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: Some of the time	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: Most of the time	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: All of the time	28. Your child has to use written lists more often than other people his/her age so he/she will not forget things.: Not Applicable
29. Your child has trouble remembering to do things like school projects or chores.	29. Your child has trouble remembering to do things like school projects or chores.: None of the time	29. Your child has trouble remembering to do things like school projects or chores.: A little of the time	29. Your child has trouble remembering to do things like school projects or chores.: Some of the time	29. Your child has trouble remembering to do things like school projects or chores.: Most of the time	29. Your child has trouble remembering to do things like school projects or chores.: All of the time	29. Your child has trouble remembering to do things like school projects or chores.: Not Applicable
30. It is hard for your child to concentrate in school.	30. It is hard for your child to concentrate in school.: None of the time	30. It is hard for your child to concentrate in school.: A little of the time	30. It is hard for your child to concentrate in school.: Some of the time	30. It is hard for your child to concentrate in school.: Most of the time	30. It is hard for your child to concentrate in school.: All of the time	30. It is hard for your child to concentrate in school.: Not Applicable
31. Your child has trouble paying attention to the teacher.	31. Your child has trouble paying attention to the teacher.: None of the time	31. Your child has trouble paying attention to the teacher.: A little of the time	31. Your child has trouble paying attention to the teacher.: Some of the time	31. Your child has trouble paying attention to the teacher.: Most of the time	31. Your child has trouble paying attention to the teacher.: All of the time	31. Your child has trouble paying attention to the teacher.: Not Applicable
32. Your child has to work really hard to pay attention or he/she makes mistakes.	32. Your child has to work really hard to pay attention or he/she makes mistakes.: None of the time	32. Your child has to work really hard to pay attention or he/she makes mistakes.: A little of the time	32. Your child has to work really hard to pay attention or he/she makes mistakes.: Some of the time	32. Your child has to work really hard to pay attention or he/she makes mistakes.: Most of the time	32. Your child has to work really hard to pay attention or he/she makes mistakes.: All of the time	32. Your child has to work really hard to pay attention or he/she makes mistakes.: Not Applicable