Client and other details

Client first name *

Client last name *

Client date of birth *

Please enter the client's legal name so our system can match them correctly...

Your first name *

Your last name *

Relationship to the client *

Your mobile number *

Your email address

You are being asked to describe the behaviour of someone you know well. How often did that person experience each of these problems? Please select the answer next to each item below that best describes their behaviour when they were a child between 5 and 12 years of age.

Section 1 (Inattention)

1. Failed to give close attention to details or make careless mistakes in their work or other activities *

Never or rarelySometimesOftenVery often

2. Had difficulty sustaining attention in tasks or fun activities *

Never or rarelySometimesOftenVery often

3. Didn't listen when spoken to directly *

Never or rarelySometimesOftenVery often

4. Didn't follow through on instructions and failed to finish work or chores *

Never or rarelySometimesOftenVery often

5. Had difficulty organising tasks and activities *

Never or rarelySometimesOftenVery often

6. Avoided, disliked, or was reluctant to engage in tasks that require sustained mental effort *

Never or rarelySometimesOftenVery often

7. Lost things necessary for tasks or activities *

Never or rarelySometimesOftenVery often

8. Was easily distracted by extraneous stimuli or irrelevant thoughts *

Never or rarelySometimesOftenVery often

9. Was forgetful in daily activities *

Never or rarelySometimesOftenVery often

Inattention score

Inattention symptom count

Section 2 (Hyperactivity)

10. Fidgeted with hands or feet or squirmed in seat *

Never or rarelySometimesOftenVery often

11. Left seat in classrooms or in other situations in which remaining seated was expected *

Never or rarelySometimesOftenVery often

12. Shifted around excessively or felt restless or hemmed in *

Never or rarelySometimesOftenVery often

13. Had difficulty engaging in leisure activities quietly (felt uncomfortable, or was loud or noisy) *

Never or rarelySometimesOftenVery often

14. Was “on the go” or acted as if “driven by a motor” (or felt like they had to be busy or always doing something) *

Never or rarelySometimesOftenVery often

Hyperactivity score

Hyperactivity symptom count

Section 3 (Impulsivity)

15. Talked excessively (in social situations) *

Never or rarelySometimesOftenVery often

16. Blurted out answers before questions have been completed, completed others’ sentences, or jumped the gun *

Never or rarelySometimesOftenVery often

17. Had difficulty awaiting their turn *

Never or rarelySometimesOftenVery often

18. Interrupted or intruded on others (butted into conversations or activities without permission or took over what others were doing) *

Never or rarelySometimesOftenVery often

Impulsivity score

Impulsivity symptom count

Total ADHD Score

Section 1 Symptom Count

Sum of Sections 2 and 3 Symptom Counts

Total ADHD Symptom Count

19. In which of these settings did those symptoms impair their functioning?

School Home Social relationships

School difficulties

Home difficulties

Social relationship difficulties

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