QbCheck Rating Form 18+ Years

QbCheck Rating Scale 18+ Years

The QbCheck Rating Scale adds a subjective perspective to the evaluation process. The scale is developedfrom the 18 questions in the DSM-5, a handbook used by healthcare professionals, describing patterns ofbehaviour associated with ADHD. Each behaviour is graded as Never or Rarely, Sometimes, Often and Very often.
Name

First NameLast Name
Date of Birth

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Gender
Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number

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Email address (that you would like the results sent to)
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Completion Date

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Answers Completed By

Please answer the following questions (Inattention)

	Never	Rarely	Sometimes	Often	Very Often
Difficulty paying attention to details or makes careless mistakes unless interested
Difficulty staying focused unless interested
Difficulty listening when spoken to directly
Difficulty following through on tasks
Difficulty organising and managing tasks
Avoiding sustained mental effort unless interested
Losing things
Easily distracted by the environment and unrelated thoughts
Forgetful

Please answer the following questions (Hyperactivity/Impulsivity)

	Never	Rarely	Sometimes	Often	Very Often
Fidgeting or squirming in my chair
Finding reasons to leave my seat when expected to remain seated
Moving about excessively or feeling restless
Difficulty engaging in leisure activities quietly
Feeling uncomfortable being still for extended time periods
Talks excessively
Blurting out answers or thoughts
Has difficulty waiting turn
Interrupting or imposing on others

Additional Information
Have these symptoms always been present?
Is there any family history of ADHD/Autism? Is so please give details.*
Is there any history of trauma and/or mental health issues? Is so please give details.*
Please can you describe how these symptoms affect your life on a daily basis below:*
Please can you describe how these symptoms affected your education/behaviour at school:*
What sort of strategies have you tried to manage your symptoms?*
What outcome(s) are you looking for from this assessment?
At ABC Children's Therapy we take your privacy very seriously and only use your personal information to provide you with access to our therapy. This document will be retained for 7 years in accordance with the Data Protection Act (DPA) 1998.
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Additional Information