Your details

First name *

Last name *

Date of birth *

Please enter your legal name so our system can match you correctly...

Please select the answer next to each item below that best describes your behaviour when you 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 my work or other activities *

Never or rarelySometimesOftenVery often

2. Had difficulty sustaining my 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 fail 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 my 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. I was “on the go” or acted as if “driven by a motor” (or I felt like I 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 my 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 your functioning?

School Home Social relationships

School difficulties

Home difficulties

Social relationship difficulties

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