ADHD Adult Pre-Assessment Questionnaire

ADHD Adult Pre-Assessment Questionnaire

Please complete this confidential questionnaire to assist with your ADHD assessment. Answer each section as thoroughly as possible.
Please note that this is a lengthy questionnaire. If you need to pause and return later, please use the Save button at the bottom of the form.

Screening Assessment Service*

Comprehensive ADHD Assessment

$550.00NZD Quantity

Total

$0.00NZD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Personal Information

Please provide your basic details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Are you enrolled with us?
Email Address*
example@example.com
Phone Number*

Phone Number
Gender*
Residential Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation/ Most recent role
Who referred you for this assessment?
What are your main concerns or reasons for seeking an ADHD assessment?*
Childhood Difficulties (before age 12)

Inattention (e.g., easily distracted, difficulty finishing tasks)Hyperactivity (e.g., fidgeting, always on the go)Impulsivity (e.g., blurting out answers, interrupting others)Academic difficultiesBehavioral difficulties at home or schoolSocial difficulties (e.g., making/keeping friends)Other
Please describe any difficulties or symptoms you experienced in childhood.
Developmental History

Normal birth and developmentDelayed speech/language developmentDelayed motor development (e.g., walking, coordination)Learning disabilitiesOther developmental concerns
Please provide details about your early development, including any delays or concerns.
Medical History

No significant medical historyNeurological conditions (e.g., epilepsy, head injury)Chronic illnessesSensory impairments (vision, hearing)Sleep disordersOther
Please list any current medications and medical conditions.
Mental Health History

No history of mental health difficultiesDepressionAnxietyBipolar disorderObsessive-compulsive disorderPsychosisSelf-harm or suicidal thoughtsEating disorderOther
Please describe any past or current mental health difficulties, including treatments received.
Substance Use History

No history of substance useAlcoholNicotineCannabisStimulants (e.g., cocaine, amphetamines)Other recreational drugs
Please provide details about any substance use, including frequency and duration.
Family Psychiatric History

No known family psychiatric historyADHDAutism spectrum disorderLearning disabilitiesDepressionAnxietyBipolar disorderOther
Please specify which family members have had psychiatric or neurodevelopmental conditions.
Sleep Health

No sleep difficultiesDifficulty falling asleepDifficulty staying asleepEarly morning wakingExcessive daytime sleepinessUse of sleep medicationOther
Please describe your current sleep patterns and any concerns.
Cultural / Social Context

No significant cultural or social factorsRecent major life changes (e.g., move, job loss)Relationship difficultiesSocial isolationDiscrimination or stigmaOther
Please provide any additional information about your cultural, social, or environmental context that may be relevant.
Strengths and Interests
Document Checklist (please indicate which documents you are submitting)

School reportsPrevious assessmentsMedical recordsOther relevant documents
Upload supporting documents (optional)

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Adult ADHD Self-Report Scale (ASRS-v1.1)

ASRS-v1.1 Symptom Checklist – Part A and Part B*

Rows	Never	Rarely	Sometimes	Often	Very Often
Q1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
Q2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
Q3. How often do you have problems remembering appointments or obligations?
Q4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Q5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
Q6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
Q7. How often do you make careless mistakes when you have to work on a boring or difficult project?
Q8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
Q9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
Q10. How often do you misplace or have difficulty finding things at home or at work?
Q11. How often are you distracted by activity or noise around you?
Q12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
Q13. How often do you feel restless or fidgety?
Q14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
Q15. How often do you find yourself talking too much when you are in social situations?
Q16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
Q17. How often do you have difficulty waiting your turn in situations when turn taking is required?
Q18. How often do you interrupt others when they are busy?

Please answer the questions below, rating yourself on each of the criteria shown. As you answer each question, select the box that best describes how you have felt and conducted yourself over the past 6 months.
Score 4 or more consistent with ADHD
PHQ-9 Assessment

Select the option that best describes how often each problem has bothered you.

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

Rows	Not at all	Several days	More than half the days	Nearly every day
1) Little interest or pleasure in doing things
2) Feeling down, depressed, or hopeless
3) Trouble falling or staying asleep, or sleeping too much
4) Feeling tired or having little energy
5) Poor appetite or overeating
6) Feeling bad about yourself – or that you are a failure or have let yourself or your family down
7) Trouble concentrating on things, such as reading the newspaper or watching television
8) Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
9) Thoughts that you would be better off dead or of hurting yourself in some way

This checklist is a screening tool and does not by itself establish a diagnosis. Please discuss your responses with your healthcare professional.
PHQ-9 Total Score
Level of Distress
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
GAD-7 Assessment

Please answer the following questions about how you have been feeling over the last 2 weeks. This screening is not a diagnosis but can help you and your provider understand your symptoms.
Over the last 2 weeks, how often have you been bothered by the following problems? (GAD-7)

Select the option that best describes how often each problem has bothered you.

GAD-7 Assessment*

Rows	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

GAD-7 Total Score
Level of Anxiety

Functional Impact of Current Difficulties *

Rows	No Impact	Low Impact	Moderate Impact	Significant Impact	Severe Impact
Work/Study
Home organisation
Social life
Romantic relationships
Emotional wellbeing
Self-care (sleep, meals, hygiene)
Financial management

Adult Funcitioning & Work History

As an adult, describe your general functioning:
Organisation
Time management
Completing tasks and projects
How have your attention, organisation, or impulsivity affected your work or career?
Weiss Functional Impairment Assessment

Select the option that best describes how your emotional or behavioural problems have affected each item in the last month

Family

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Having problems with family
Having problems with spouse/partner
Relying on others to do things for you
Causing fighting in the family
Makes it hard for the family to have fun together
Problems taking care of your family
Problems balancing your needs againt those of your family
Problems losing control with family

Family

Work

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Problems performing required duties
Problems with getting your work done efficiently
Problems with your supervisor
Problems keeping a job
Getting fired from work
Problems working in a team
Problems with your attendance
Problems with being late
Problems taking on new tasks
Problems working to your potential
Poor performance evaluations

Work

School

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Problems taking notes
Problems completing assignments
Problems getting your work done efficiently
Problems with teachers
Problems with school administrators
Problems meeting minimum requirements to stay in school
Problems with your attendance
Problems with being late
Problems working to your potential
Problems with inconsistent grades

School

Life Skills

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Excessive or inappropriate use of internet, video games or TV
Problems keeping an acceptable appearance
Problems getting ready to leave the house
Problems getting to bed
Problems with nutrition
Problems with sex
Problems with sleeping
Getting hurt or injured
Avoiding exercise
Problems keeping regular appointments with doctor/dentist
Problems keeping up with household chores
Problems managing money

Life Skills

Self-Concept

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Feeling bad about yourself
Feeling frustrated with yourself
Feeling discouraged
Not feelin happy with your life
Feeling incompetent

Self Concept

Social

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Getting into arguments
Trouble cooperating
Trouble getting along with people
Problems having fun with other people
Problems participating in hobbies
Problems making friends
Problems keeping friends
Saying inapproporiate things
Complaints from neighbours

Social

Risk

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Aggressive driving
Doing other things while driving
Road rage
Breaking or damaging things
Doing things that are illegal
Being involved with the police
Smoking cigarettes
Smoking marijuana
Drinking alcohol
Taking "street" drugs
Sex without protection (birth control, condom)
Sexually inappropriate behaviour
Being physically aggressive
Being verbally aggressive

Risk
Should be Empty:

ADHD Adult Pre-Assessment Questionnaire

Please note that this is a lengthy questionnaire. If you need to pause and return later, please use the Save button at the bottom of the form.

Personal Information

Adult ADHD Self-Report Scale (ASRS-v1.1)

PHQ-9 Assessment

GAD-7 Assessment

Over the last 2 weeks, how often have you been bothered by the following problems? (GAD-7)

Adult Funcitioning & Work History

Weiss Functional Impairment Assessment