Behaviour Scale form

Date of birth  Required
Address  Required
Date  Optional

Adult ADHD: Childhood Behaviour Scale Informant Report

PLEASE DO NOT FILL THIS IN YOURSELF ASK A RELATIVE OR SOMEONE WHO KNEW YOU AS A CHILD TO COMPLETE IT

PLEASE RATE BEHAVIOUR BETWEEN 7 and 12 YEARS OF AGE

Please select the number that best describes the behaviour when this person was a child.
1. Failed to give close attention to details or made careless mistakes in work  Optional
2. Fidgeted with hands or feet or squirmed in seat  Optional
3. Had difficulty sustaining attention in tasks or fun activities  Optional
4. Left seat in classroom or other situations in which sitting was expected  Optional
5. Didn’t listen when spoken to directly  Optional
6. Restless in the “squirmy” sense  Optional
7. Didn’t follow through on instructions and failed to finish work  Optional
8. Had difficulty engaging in leisure activities or doing fun things quietly  Optional
9. Had difficulty organising tasks and activities  Optional
10. Felt “on the go” or acted as if “driven by a motor”  Optional
11. Avoided, disliked, or was reluctant to engage in work that required sustained mental effort  Optional
12. Talked excessively  Optional
13. Lost things necessary for tasks or activities  Optional
14. Blurted out answers before questions had been completed  Optional
15. Easily distracted  Optional
16. Had difficulty awaiting turn  Optional
17. Forgetful in daily activities  Optional
18. Interrupted or intruded on others  Optional

To what extent did the problems circled on the previous page interfere with their ability to function in each of these areas of life activities when they were a child between 7 and 12 years of age?
1. In their home life with their immediate family  Optional
2. In their social interactions with other children  Optional
3. In their activities or dealings in the community  Optional
4. In school  Optional
5. In sports, clubs, or other organisations  Optional
6. In learning to take care of themselves  Optional
7. In their play, leisure or recreational activities  Optional
8. In their handling of daily chores or other responsibilities  Optional

Instruction to Clinician: This form must be completed and accompany any referral for assessment of possible adult ADHD.

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