CURRENT BEHAVIOR SCALE – PARTNER/SPOUSE REPORT

Patient Name*

Patient's Birth Date*

MonthDayYear

Who is your Partner's/Spouse's Provider?*

Instructions
Please select the item that best describes your partner’s behavior

DURING THE PAST 6 MONTHS*

Rows	Never or rarely	Sometimes	Often	Very Often
1. Fails to give close attention to details or make careless mistakes in work
2. Fidgets with hands or feet or squirm in seat
3. Has difficulty sustaining attention in tasks or fun activities
4. Leaves seat in situations in which sitting is expected
5. Appears not to listen when spoken to directly
6. Appears restless
7. Does not follow through on instructions and fails to finish work
8. Has difficulty engaging in leisure activities or doing fun things quietly
9. Has difficulty organizing tasks and activities
10. Appears to be “on the go all the time ” or as if “driven by a motor”
11. Avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort
12. Talk excessively
13. Loses things necessary for tasks or activities
14. Blurts out answers before questions have been completed
15. Easily distracted
16. Has difficulty awaiting turn
17. Forgetful in daily activities
18. Interrupts or intrude on others

To what extent do the problems you may have circled on the previous page interfere with your partner’s ability to function in each of these areas of life activities?*

Rows	Never or Rarely	Sometimes	Often	Very Often
In his/her home life with immediate family
In his/her work or occupation
In his/her social interactions with others
In his/her activities or dealings in the community
In any educational activities
In your dating or marital relationship
In his/her management of money
In his/her ability to drive a motor vehicle
In his/her leisure or recreational activities
In his/her leisure or recreational activities

Date