ADHD Assessment Form
SECTION 1: Personal and Contextual Information
Personal Details:
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First Name
Last Name
Date of Birth:
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-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Email:
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example@example.com
Current Living Arrangements (People you live with):
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Rows
Name
Relationship
Age
1
2
3
4
Current Work/Study Status:
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Are you currently working, studying, or doing something else (e.g., parenting, volunteering)? Please briefly describe what you're doing right now, how it's going for you, and whether you're happy with it.
Reason for Referral / What Brought You Here:
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What made you (or someone else) seek an ADHD assessment now? Was there something specific that happened or changed recently — like challenges at work, school, home, or in relationships — that made you want to explore this? (There are no right or wrong answers — just tell us what you’ve noticed or what’s been on your mind.)
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What Are You Hoping to Gain from This Assessment?
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Is there something you're hoping to understand better about yourself? For example, are you looking for clarity, support with challenges, a diagnosis, treatment options, or just to make sense of your experiences? (Feel free to write whatever comes to mind — this helps us understand how to best support you.)
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SECTION 2: ADHD History and Concerns
Have you been previously diagnosed with ADHD?
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Yes
No
If yes: At what age? By whom? What treatment was provided?)
What are your current concerns or questions about ADHD?
*
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SECTION 3: Inattention Symptoms
Please select the rating that best reflects how you have felt and behaved over the past few months. If you select "Often", "Very Often" and “Sometimes” for any question, please provide specific examples from both your childhood/adolescence and adulthood.
Do you fail to give close attention to details or make careless mistakes in school, work or other activities?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER and ADULTHOOD
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Do you have trouble sustaining attention in tasks?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
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When spoken to directly, do you find it difficult to listen?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
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Do you find it difficult to follow through on instructions,and fail to finish tasks because you get distracted / side-tracked?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
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Do you have trouble organising activities and tasks?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you avoid, dislike or are reluctant to do tasks which require mental effort over long periods of time (e.g. schoolwork/homework)?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you lose things that are necessary for tasks andactivities (keys, paperwork, glasses, phone, school materials, tools, wallets)?
*
Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
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SECTION 4: Hyperactivity and Impulsivity Symptoms
Please select the rating that best reflects how you have felt and behaved over the past few months. If you select "Often", "Very Often" and “Sometimes” for any question, please provide specific examples from both your childhood/adolescence and adulthood.
Do you fidget, tap your hands or feet, or squirm in your seat?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
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Do you leave your seat in situations when remaining seated is expected?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
If you have to remain still, do you feel restless?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Is it hard for you take part in leisure activities quietly?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you feel as if you are always ‘on the go’?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you talk excessively?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you blurt out an answer before the question has been completed?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you have trouble waiting your turn?
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
Do you interrupt others? (butting into conversations or games?)
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Never
Rarely
Sometimes
Often
Very Often
If “Often”, “Very Often” or “Sometimes”, please provide examples: CHILDHOOD / TEENAGER AND ADULTHOOD
0/0
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SECTION 5: Co-occurring Psychiatric Symptoms
Emotional Dysregulation (e.g., mood swings, outbursts): Can you describe any times when you’ve experienced emotional outbursts or felt emotionally unstable? What was happening at the time, and how often does this occur?
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0/0
Anxiety / Panic / PTSD Symptoms: Have you experienced anxiety, panic attacks, or symptoms related to past traumatic events? If so, please describe what these experiences are like for you and how frequently they occur.
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0/0
Obsessive or Compulsive Behaviours: Have you ever experienced obsessive thoughts or felt compelled to perform certain actions or rituals? Please describe what these thoughts or behaviours are, and when they typically occur.
*
0/0
Mood Symptoms (depression, low energy, self-harm thoughts): Can you describe any experiences with low mood, lack of motivation or pleasure, low energy, or thoughts of self-harm? How often do these feelings come up, and how do they affect your day-to-day life?
*
0/0
Sleep Difficulties (falling/staying asleep, early waking): Have you noticed any difficulties with sleep (e.g., falling asleep, staying asleep, waking too early, or oversleeping)? Please describe what your sleep patterns are like and any changes you’ve noticed overtime.
*
0/0
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SECTION 6: Daily Functioning
Exercise Habits (type, frequency): Can you describe your current exercise routine, if any? How often do you engage in physical activity, and what types of exercise do you usually do?
*
0/0
Current Illnesses, Treatment or Medications: Are you currently managing any medical or mental health conditions? Please list any diagnoses, treatments, or medications you're currently taking, and include anything you feel is important for us to know.
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Current Stressors: What are some current stressors in your life, if any? You may wish to comment on areas such as relationships, finances, work or study, legal issues (e.g., driving matters, custody, fines), or anything else that feels relevant.
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0/0
Strengths and Interests: What would you say are your personal strengths and interests? Feel free to share what you enjoy doing, what you're passionate about, or what others often appreciate about you.
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0/0
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SECTION 7: Developmental and Educational History
Where were you born?
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Location of Birth
Childhood Development Issues (e.g., milestone, delays): Did you experience any difficulties or concerns during early childhood (e.g., developmental delays, health issues, behavioural concerns)? If so, please describe them.
*
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What was your experience like at primary school? Please share the name of the school, what you enjoyed, and anything you found challenging.
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0/0
What was your experience like during high school? Include the name of the school, what aspects of school life you enjoyed, and what you found difficult.
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0/0
Any Available School Reports: If you have access to past school reports, what kinds of comments or observations were made about you (e.g., learning style, behaviour, strengths or struggles)? Please feel free to summarise or attach copies below.
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Childhood Trauma (e.g., bullying, abuse, neglect): Have you experienced any significant or traumatic events during your childhood (e.g., loss, migration, abuse, neglect, bullying)? Please describe these experiences and how they affected you.
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0/0
Tertiary Education (completion, challenges): Have you completed any tertiary or further education(e.g., TAFE, university)? Please describe your experiences, including any learning difficulties, challenges with completing your course, or successes you’d like to share.
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0/0
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SECTION 8: Occupational and Relationship History
Employment History (jobs, duration, difficulties, successes): What jobs have you had in the past, and how long did you stay in each?
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0/0
What did you enjoy most about working? What did you find difficult?
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0/0
Relationship History (partners, length, separation reasons): Have you been in a long-term relationship or partnership? If so, how long were you together and why did it end (if it did)?
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0/0
Children (name, ages): Do you have any children?
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0/0
Significant Achievements: What are some things you're most proud of in your life so far?
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0/0
Appreciation From Others: What do other people usually say they like about you?
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0/0
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SECTION 9: Psychiatric, Medical, Family, and Substance Use History
Mental Health History (Diagnoses, Treatment, Hospitalisation): Have you ever experienced mental health conditions like anxiety, depression, bipolar disorder, or psychosis? If yes, what were you diagnosed with, what treatment did you receive, and were you ever hospitalised?
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0/0
Physical Health History(Illnesses, Injuries, Medications: Have you ever had any health issues like high blood pressure, heart problems, thyroid issues, glaucoma, tics or Tourette’s, or epilepsy? Please also mention any major illnesses, injuries, surgeries, or medications you've taken regularly.
*
0/0
Family Health History (Medical or Mental Health Conditions): Does anyone in your family have a history of conditions like ADHD, depression, bipolar disorder, suicide, tics or Tourette’s, sudden death, or heart rhythm problems (like ventricular arrhythmia)?
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0/0
Substance Use (Current and Past): Have you ever used alcohol, tobacco, cannabis, or other substances? If yes, please fill in the table below with what you've used, how it affects you, how much it costs per week, and whether you're trying to stop.
Rows
Effects/ Benefits/ Drawbacks
Cost/ Week
Are you trying to stop?
Caffeine (Tea, Coffee)
Energy Drinks
Cigarettes
Alcohol
Cannabis
Stimulants – E.g., Cocaine, Ice, Speed
Opiates – Heroine, Codeine
If Other (Please Specify)
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