ADHD Adulthood Informant PAQ - The Online Therapy Clinic

ADHD Adulthood Informant PAQ

Adulthood Informant PAQ (Adult ADHD – DSM-V)

This form should be completed by someone who knows the individual well and can describe their symptoms over the past six months.

Patient Name & DOB:

Your Details

Your name:(Required)

Your relationship to the individual being assessed:(Required)

Length of time you have known the individual being assessed:(Required)

Clinician Name

DSM-V Adulthood Observer: Inattention

Fails to give close attention to details or makes careless mistakes in work(Required)

Please provide any additional information or examples:

Has difficulty sustaining attention in tasks or fun activities(Required)

Please provide any additional information or examples:

Appears not to listen when spoken to directly(Required)

Please provide any additional information or examples:

Doesn’t follow through on instructions and fails to finish work(Required)

Please provide any additional information or examples:

Has difficulty organising tasks and activities(Required)

Please provide any additional information or examples:

Avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort(Required)

Please provide any additional information or examples:

Easily distracted(Required)

Please provide any additional information or examples:

Forgetful in daily activities(Required)

Additional comments:

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

Please provide any additional information or examples:

DSM-V Adulthood Observer: Hyperactivity

Fidgets with hands or feet or squirms in their seat(Required)

Please provide any additional information or examples:

Leaves their seat in situations where sitting is expected(Required)

Please provide any additional information or examples:

Appears restless(Required)

Please provide any additional information or examples:

Has difficulty engaging in leisure activities or doing fun things quietly(Required)

Please provide any additional information or examples:

Appears to be ‘on the go’ all the time or as if driven by a motor(Required)

Please provide any additional information or examples:

Talks excessively(Required)

Please provide any additional information or examples:

DSM-V Adulthood Observer: Impulsivity

Blurts out answers before questions have been completed(Required)

Please provide any additional information or examples:

Has difficulty awaiting their turn(Required)

Please provide any additional information or examples:

Interrupts or intrudes on others(Required)

Please provide any additional information or examples:

Additional Questions

To what extent do the problems interfere with their ability to function?

In their home life with immediate family(Required)

Additional examples:

In their work or occupation(Required)

Additional examples:

In their social interactions with others(Required)

Additional examples:

In their activities or dealings in the community(Required)

Additional examples:

In any educational/academic activities(Required)

Additional examples:

In their dating or marital relationship(Required)

Additional examples:

In their management of money and finances(Required)

Additional examples:

In their ability to drive a motor vehicle(Required)

Additional examples:

In their leisure or recreational activities(Required)

Additional examples:

In their management of daily responsibilities(Required)

Additional examples:

Additional Information

Do you have any other concern in regard to their mood or mental health, or anything else you think may be helpful to comment upon?(Required)

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