Adhd Patient PAQ

Patient PAQ - Adult ADHD (DSM-V)

This questionnaire asks you about your development from birth to help with the assessment process. You may wish to ask someone who knew you well as a child to assist with the first sections.

Please answer as fully as you can. This questionnaire also contains two standardised measures – the BAARS IV and the ASRS. Read all instructions and questions carefully, and select the most accurate answers.

Personal Details

Your full name:(Required)

Your date of birth:(Required)

Gender assigned at birth:(Required)

Gender you identify as and preferred pronouns:(Required)

Mobile telephone number:(Required)

Personal email address:(Required)

GP details (name, address, phone, email):(Required)

Clinician Name

Informant Details

We require contact details for someone who knows you well as an adult to complete a short questionnaire about your recent behaviours and symptoms. If possible, please also provide details for someone who knew you as a child.

ADULTHOOD informant name and relationship:(Required)

ADULTHOOD informant personal email(Required)

CHILDHOOD informant name and relationship:(Required)

CHILDHOOD informant personal email:(Required)

Reason for Referral

Briefly explain why you are seeking an ADHD assessment, including any specific concerns, symptoms, or professional recommendations.(Required)

Personal History

Family background:(Required)

Include details about your parents and siblings, their education and occupations, any major family moves, and significant life events.

Mother’s pregnancy and your birth:(Required)

Include length of pregnancy, any health issues, whether your mother smoked or drank alcohol, delivery details, feeding method, and any events considered important.

Early development:(Required)

Describe when you reached key milestones such as walking and talking, how this compared with siblings or peers, and any notable personality traits or behaviours.

Primary school:(Required)

Summarise academic performance, handwriting and reading skills, friendships, behaviour in class, any incidents of bullying, and accidents or injuries.

Secondary school:(Required)

Comment on academic strengths and weaknesses, friendships, discipline issues, any experiences with bullying, substance use, and relationships.

GCSEs and A-Levels:(Required)

List subjects taken, grades achieved, and whether results met expectations compared with peers.

Adult relationships and education/employment:(Required)

Outline romantic and family relationships, friendships, higher education, jobs held, and major career changes.

Current social circumstances and goals:(Required)

Describe your current living arrangements, work situation, relationships, hobbies, and personal goals.

DSM-V Self-Report (Childhood Symptoms): Inattention

Failed to give close attention to details or made careless mistakes in your work or other activities:(Required)

Additional comments:

Difficulty sustaining your attention in tasks or fun activities:(Required)

Additional comments:

Didn’t listen when spoken to directly:(Required)

Additional comments:

Didn’t follow through on instructions and failed to finish work or chores:(Required)

Additional comments:

Had difficulty organising tasks and activities:(Required)

Additional comments:

Avoided, disliked, or were reluctant to engage in tasks that require sustained mental effort:(Required)

Additional comments:

Lost things necessary for tasks or activities:(Required)

Additional comments:

Forgetful in daily activities:(Required)

Additional comments:

Easily distracted by extraneous stimuli or irrelevant thoughts:(Required)

Additional comments:

DSM-V Self-Report (Childhood Symptoms): Hyperactivity

Fidgeted with hands or feet or squirmed in seat:(Required)

Additional comments:

Left your seat in classrooms or in other situations in which remaining seated was expected:(Required)

Additional comments:

Shifted around excessively or felt restless or felt restless or 'hemmed in' :(Required)

Additional comments:

Had difficulty engaging in leisure activities quietly:(Required)

Additional comments:

Felt 'on the go' or acted as if 'driven by a motor':(Required)

Additional comments:

Talked excessively:(Required)

Additional comments:

DSM-V Self-Report (Childhood Symptoms): Impulsivity

Blurted out answers before questions had been completed, completed others’ sentences, or 'jumped the gun':(Required)

Additional comments:

Difficulty waiting your turn:(Required)

Additional comments:

Interrupted or intruded on others:(Required)

Additional comments:

DSM-V Self-Report (Childhood Symptoms): Impact on Daily Life

In your home life with your immediate family:(Required)

Additional comments:

In your social interactions with other children:(Required)

Additional comments:

In your activities or dealings in the community:(Required)

Additional comments:

In school:(Required)

Additional comments:

In sports, clubs or other organisations:(Required)

Additional comments:

In learning to take care of yourself:(Required)

Additional comments:

DSM-V Self-Report (Current Symptoms): Inattention

Fail to give close attention to details or make careless mistakes in my work or other activities:(Required)

Additional comments:

Difficulty sustaining my attention in tasks or fun activities:(Required)

Additional comments:

Don't listen when spoken to directly:(Required)

Additional comments:

Don't follow through on instructions and fail to finish work or chores:(Required)

Additional comments:

Have difficulty organising tasks and activities:(Required)

Additional comments:

Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort:(Required)

Additional comments:

Lose things necessary for tasks or activities:(Required)

Additional comments:

Easily distracted by extraneous stimuli or irrelevant thoughts:(Required)

Additional comments:

Forgetful in daily activities:(Required)

Additional comments:

DSM-V Self-Report (Current Symptoms): Hyperactivity

Fidget with hands or feet or squirm in seat:(Required)

Additional comments:

Leave my seat during situations in which remaining seated is expected:(Required)

Additional comments:

Shift around excessively or feel restless or 'hemmed in':(Required)

Additional comments:

Have difficulty engaging in leisure activities quietly:(Required)

Additional comments:

I am 'on the go' or act as if 'driven by a motor':(Required)

Additional comments:

Talk excessively:(Required)

Additional comments:

DSM-V Self-Report (Current Symptoms): Impulsivity

Blurt out answers before questions have been completed, complete others' sentences, or jump the gun:(Required)

ADHD Patient PAQ

Patient PAQ - Adult ADHD (DSM-V)

Personal Details

Informant Details

Reason for Referral

Personal History

DSM-V Self-Report (Childhood Symptoms): Inattention

DSM-V Self-Report (Childhood Symptoms): Hyperactivity

DSM-V Self-Report (Childhood Symptoms): Impulsivity

DSM-V Self-Report (Childhood Symptoms): Impact on Daily Life

DSM-V Self-Report (Current Symptoms): Inattention

DSM-V Self-Report (Current Symptoms): Hyperactivity

DSM-V Self-Report (Current Symptoms): Impulsivity

DSM-V Self-Report (Current Symptoms): Impact on Daily Life

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