Multi-Health Systems, Inc.

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Multi-Health Systems, Inc.

CONNERS 4™ PARENT
RESPONSE BOOKLET C. Keith Conners, PhD

Instructions:
Here are some things parents might say about their children. Please read each item carefully. Indicate how true
it is of your child or how often it happened in the past month. Think about whether:

0 = In the past month, this was not true at all about my child. It never or rarely happened.
1 = In the past month, this was just a little true about my child. It happened occasionally.
2 = In the past month, this was pretty much true about my child. It happened often or quite a bit.
3 = In the past month, this was completely true about my child. It happened very often or always.

Please circle only one answer for each item. If you want to change your answer, put an X through it and circle your
new choice. Be sure to answer every item. For items that you find difficult to answer, please give your best guess.

*Required field

CHILD BEING DESCRIBED YOUR INFORMATION

First Name:* First Name:
Last Name:* Last Name:
ID:* (or First and Last Name) ID:
Birth Date:* (MMM) / (DD) / (YYYY) Relationship to Child:
Age:* Biological parent
Gender: Non-biological parent (Please specify)
Male Other relative/guardian (Please specify)
Female

Other (Please specify)

Grade:

Today’s Date:* (MMM) / (DD) / (YYYY)

Copyright © 2022 Multi-Health Systems, Inc. (MHS, Inc.). All rights reserved.
In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003.
In Canada, 3770 Victoria Park Ave., Toronto, ON M2H 3M6, 1-800-268-6011, 1-416-492-2627,
FORM CODE: 4 Fax 1-416-492-3343. International, +1-416-492-2627. Fax, +1-416-492-3343 or (888)540-4484.
CONNERS 4™ PARENT · C. Keith Conners, PhD
Child’s Name/ID: Today’s Date: (MMM) / (DD) / (YYYY)
Think about your child in the past month.
0 = Not true at all 1 = Just a little true 2 = Pretty much true 3 = Completely true
(Never/Rarely) (Occasionally) (Often/Quite a bit) (Very often/Always)
1. Gets invited to play or go out with others. 0 1 2 3
2. Is forgetful in daily activities. 0 1 2 3
3. Leaves their seat when they should stay seated. 0 1 2 3
4. Loses temper. 0 1 2 3
5. Avoids or dislikes things that take a lot of effort and are not fun. 0 1 2 3
6. Has trouble getting started on tasks or projects. 0 1 2 3
7. Is sad, gloomy, or irritable. 0 1 2 3
8. Blurts out the first thing that comes to mind. 0 1 2 3

Copyright © 2022 Multi-Health Systems, Inc. (MHS, Inc.). All rights reserved. In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-
9. Is easily distracted. 0 1 2 3
10. Has trouble falling or staying asleep. 0 1 2 3
11. Gets a headache when they have to pay attention for a long time. 0 1 2 3
12. Disrupts family activities. 0 1 2 3
13. Needs to be moving around. 0 1 2 3
14. Doesn't seem to listen to what people are saying to them. 0 1 2 3
15. Actively refuses to follow the rules. 0 1 2 3
16. Isn't aware that they are being loud. 0 1 2 3

3003. In Canada, 3770 Victoria Park Ave., Toronto, ON M2H 3M6, 1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343.
17. Doesn't finish schoolwork, work, or other tasks. 0 1 2 3
18. Is annoying to peers. 0 1 2 3
19. Has trouble controlling their worries. 0 1 2 3
20. Doesn't know what their homework is or where they put it. 0 1 2 3
21. Uses other people's things without asking permission. 0 1 2 3
22. Has trouble getting back on task after being interrupted. 0 1 2 3
23. Creates stress for the family. 0 1 2 3
24. Has trouble controlling their emotions. 0 1 2 3
25. It's impossible for them to pay attention to things. 0 1 2 3
26. Fails to follow through on instructions. 0 1 2 3
27. Makes impulsive decisions. 0 1 2 3
28. Wants good things to happen to them. 0 1 2 3
29. Seems hopeless about the future. 0 1 2 3
30. Is angry and resentful. 0 1 2 3
31. Peers complain about their behavior. 0 1 2 3
32. Has trouble calming down when upset. 0 1 2 3
33. Forgets to turn in completed work. 0 1 2 3
34. Makes it hard for the family to have fun together. 0 1 2 3
35. Has difficulty managing their time. 0 1 2 3
36. Enjoys doing their favorite activity. 0 1 2 3
37. Tries to get even with people. 0 1 2 3
38. Gets tired or worn out from worrying. 0 1 2 3
39. Talks too much. 0 1 2 3
40. Has trouble concentrating. 0 1 2 3
41. Is irritable or easily annoyed by others. 0 1 2 3
42. Has difficulty waiting for their turn. 0 1 2 3
43. Runs or climbs when they are not supposed to. 0 1 2 3
44. Says or does things they don't mean to because they are angry. 0 1 2 3
FORM CODE: 4 3 of 5
CONNERS 4™ PARENT · C. Keith Conners, PhD
Child’s Name/ID: Today’s Date: (MMM) / (DD) / (YYYY)
Think about your child in the past month.
0 = Not true at all 1 = Just a little true 2 = Pretty much true 3 = Completely true
(Never/Rarely) (Occasionally) (Often/Quite a bit) (Very often/Always)

45. Causes the family to be late for appointments or activities. 0 1 2 3

46. Feels worthless. 0 1 2 3
47. Interrupts other people's conversations, games, or activities. 0 1 2 3
48. Has trouble completing schoolwork or work because of distractions. 0 1 2 3
49. Has trouble organizing tasks or activities. 0 1 2 3
50. Argues with family members. 0 1 2 3
51. Annoys other people on purpose. 0 1 2 3
52. Is unable to be quiet when playing or using free time. 0 1 2 3

Copyright © 2022 Multi-Health Systems, Inc. (MHS, Inc.). All rights reserved. In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-
53. Fails to pay close attention to details. 0 1 2 3
54. Interacts well with peers. 0 1 2 3
55. Hands things in late. 0 1 2 3
56. Gets really angry all of a sudden. 0 1 2 3
57. Makes careless mistakes in schoolwork or other activities. 0 1 2 3
58. Upsets or offends others on purpose. 0 1 2 3
59. Gets overly excited. 0 1 2 3
60. Has trouble planning ahead. 0 1 2 3

3003. In Canada, 3770 Victoria Park Ave., Toronto, ON M2H 3M6, 1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343.
61. Worries too much about many different things. 0 1 2 3
62. People don't want to be friends with them. 0 1 2 3
63. Hands in incomplete work or tests. 0 1 2 3
64. Intrudes on or takes over what others are doing. 0 1 2 3
65. There is nothing they can pay attention to for a long time. 0 1 2 3
66. Doesn’t get along well with family members. 0 1 2 3
67. Loses or misplaces things that they need. 0 1 2 3
68. Overreacts when they get upset. 0 1 2 3
69. Seems tired. 0 1 2 3
70. Actively refuses to do what adults tell them to do. 0 1 2 3
71. Has at least one happy memory. 0 1 2 3
72. Has trouble sitting still. 0 1 2 3
73. Gets so focused on something that they lose track of what is going on around them. 0 1 2 3
74. Creates a chaotic family life. 0 1 2 3
75. Acts before thinking. 0 1 2 3
76. Blames their mistakes or misbehavior on others. 0 1 2 3
77. Mood changes quickly and drastically. 0 1 2 3
78. Has a hard time prioritizing tasks. 0 1 2 3
79. Doesn't enjoy things like they used to. 0 1 2 3
80. Acts as if driven by a motor. 0 1 2 3
81. Is impossible to please. 0 1 2 3
82. Talks out of turn. 0 1 2 3
83. Argues with adults. 0 1 2 3
84. Appears tense, nervous, or jumpy. 0 1 2 3
85. Has trouble making or keeping friends. 0 1 2 3
86. Has a short attention span. 0 1 2 3
87. Writes reminders that they don't remember writing. 0 1 2 3
88. Has trouble changing from one task to another. 0 1 2 3
FORM CODE: 4 4 of 5
CONNERS 4™ PARENT · C. Keith Conners, PhD
Child’s Name/ID: Today’s Date: (MMM) / (DD) / (YYYY)
Think about your child in the past month.
0 = Not true at all 1 = Just a little true 2 = Pretty much true 3 = Completely true
(Never/Rarely) (Occasionally) (Often/Quite a bit) (Very often/Always)

89. Blurts out answers before the question has been completed. 0 1 2 3
90. Has trouble staying focused on work or play for a long time. 0 1 2 3
91. Fidgets or squirms in their seat. 0 1 2 3
92. Is impulsive. 0 1 2 3
93. Feels helpless. 0 1 2 3
94. Is restless. 0 1 2 3
95. Fears they will act in a way that could lead to embarrassment or rejection. 0 1 2 3
96. Has trouble controlling their anger. 0 1 2 3

Copyright © 2022 Multi-Health Systems, Inc. (MHS, Inc.). All rights reserved. In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-
97. Checks their work for mistakes. 0 1 2 3

Additional Questions:
98. Describe how these behaviors cause serious problems for your child at home, in school, at work, or with
their friends.

3003. In Canada, 3770 Victoria Park Ave., Toronto, ON M2H 3M6, 1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343.
99. Do you have any other concerns about your child?

100. What strengths or skills does your child have?

FORM CODE: 4 5 of 5