47 Pediatric Perceived Cognitive Child

Attachment 47

Pediatric Perceived Cognitive Function (PCF) – Child

On the next screens, we will ask you questions about organization, memory,
speed, concentration, and other abilities that are used in everyday life. Read each
question carefully and answer as well as you can. Please consider each question
by itself and choose an answer that really shows any problems you may have.
After you make your choice, the computer will automatically go on to the next
question. If you want to change your answer, click on the GO BACK button to
return to the question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.

ID

NQCOGped02C2

NQCOGped04C2

NQCOGped05C2

NQCOGped07C2

NQCOGped08C2

Context

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

Stem

Responses

I have a hard time keeping track of my
homework

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (I have not
been in school at all in the
last 4 weeks)

I forget to bring things to and from school
that I need for homework

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (I have not
been in school at all in the
last 4 weeks)

I forget what I am going to say

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

I have to read things several times to
understand them

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

I react slower than most people my age when
I play games

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOGped10C2

NQCOGped14C2

NQCOGped15C2

NQCOGped16C2

NQCOGped17C2

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

In the past 4 weeks,

It is hard for me to find the right words to say
what I mean

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

It takes me longer than other people to get
my school work done

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (I have not
been in school at all in the
last 4 weeks)

I forget things easily

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

I have to use written lists more often than
other people my age so I will not forget
things

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

I have trouble remembering to do things like
school projects or chores

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOGped18C2

NQCOGped19C2

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (I have not
been in school at all in the
last 4 weeks)

In the past 4 weeks,

It is hard for me to concentrate in school

In the past 4 weeks,

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (I have not
been in school at all in the
I have trouble paying attention to the teacher last 4 weeks)

NQCOGped20_2C2 In the past 4 weeks,

I have to work really hard to pay attention or
I make mistakes

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time