WeCare ADHD Clinic

1

Please read carefully before starting

This questionnaire is used to collect baseline information only to support a comprehensive ADHD assessment.

It does not diagnose ADHD and does not replace a full clinical assessment.

Diagnosis, if made, is based on a detailed structured interview.

Completing this form helps your clinician use assessment time effectively.

2

Are you currently experiencing any of the following* This field is required.

Thoughts of harming myself or others

Hearing or seeing things others cannot

Feeling unusually high, out of control, or not needing sleep

None of the above

3

I understand and agree that:* This field is required.

This is a pre-assessment questionnaire, not a diagnosis

A clinician will review my answers during an ADHD assessment

The assessment may take 1 hour or more, possibly over more than one session

Medication may not be appropriate or offered

My information will be stored securely and used for clinical care

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Name* This field is required.

First Name

Last Name

5

Please select your age range:* This field is required.For the person the assessment is being requested for

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Date of Birth* This field is required.

Date

7

Phone Number* This field is required.

Area Code

Phone Number

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Email* This field is required.

example@example.com

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NHI (if known)

10

Are you enrolled with WeCare* This field is required.

YESNO

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Preferred clinic location * This field is required.

12

Who suggested an ADHD assessment?* This field is required.

14

What are you hoping to understand or change by having an ADHD assessment?* This field is required.

15

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?* This field is required.

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How often do you have difficulty getting things in order when you have to do a task that requires organisation?* This field is required.

17

How often do you have problems remembering appointments or obligations?* This field is required.

18

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?* This field is required.

19

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?* This field is required.

20

How often do you feel overly active and compelled to do things, like you were driven by a motor?* This field is required.

21

How often do you make careless mistakes when you have to work on a boring or difficult project?* This field is required.

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How often do you have difficulty keeping your attention when you are doing boring or repetitive work?* This field is required.

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How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?* This field is required.

24

How often do you misplace or have difficulty finding things at home or at work?* This field is required.

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How often are you distracted by activity or noise around you?* This field is required.

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How often do you leave your seat in meetings or other situations in which you are expected to remain seated?* This field is required.

27

How often do you feel restless or fidgety?* This field is required.

28

How often do you have difficulty unwinding and relaxing when you have time to yourself?* This field is required.

29

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?* This field is required.

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How often do you find yourself talking too much when you are in social situations?* This field is required.

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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?* This field is required.

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How often do you have difficulty waiting your turn in situations when turn taking is required?* This field is required.

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How often do you interrupt others when they are busy?* This field is required.

34

The following questions ask about common ADHD symptoms over the last 6 months.

These questions provide baseline information only. They are not diagnostic by themselves and will be explored in more detail during your assessment.

35

Please describe specific real-life examples from the last 3–6 months that show how attention, organisation, impulsivity, or restlessness affect you. * This field is required.(This section is essential to support a valid assessment.)

36

ADHD diagnosis requires evidence that symptoms cause at least moderate impairment in two or more areas of life.* This field is required.Areas affected

Work / employment

Education / study

Home organisation / daily tasks

Relationships / family

Social life / friendships

Emotional regulation / self-esteem

Driving / safety

Health management

37

Overall impact severity* This field is required.

Mild (noticeable but manageable)

Moderate (regularly interferes with functioning)

Severe (significant ongoing impairment)

38

Please give specific examples showing how these difficulties affect your day-to-day functioning.* This field is required.

39

Were similar difficulties present before age 12?* This field is required.

Yes

No

Unsure

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Please describe any attention, behaviour, learning, or organisational difficulties before age 12, with examples if possible.* This field is required.

41

School history* This field is required.

Distractible / daydreaming

Behaviour issues

Underachievement

Needed extra learning support

Frequent comments on reports

None / unsure

42

Upload school reports or past assessments *optional

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

43

Some conditions can mimic or coexist with ADHD. These questions help your clinician make an accurate assessment.

44

Over the past 2 weeks, how often have you experienced excessive worry, feeling on edge, difficulty relaxing, or physical symptoms of anxiety, to the point that it affected your daily functioning?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

45

Over the past 2 weeks, how often have you experienced persistent low mood, loss of interest or pleasure, low energy, or negative thoughts about yourself, to the point that it affected your daily functioning?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

46

Have you ever had periods lasting several days where you felt unusually high, energised, needed little sleep, and acted impulsively?* This field is required.

No

Yes

Unsure

47

Sleep issues* This field is required.

Difficulty falling asleep

Poor sleep quality

Loud snoring / possible sleep apnoea

Excessive daytime sleepiness

Shift work

None

48

Alcohol or substance use* This field is required.

Heavy alcohol use

Cannabis weekly or more

Recreational stimulants

Nicotine dependence

None

49

Medical history* This field is required.

Heart condition

High blood pressure

Fainting / unexplained collapse

Seizures or head injury

Thyroid disorder

None

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Family history* This field is required.

Sudden cardiac death under 40

Known inherited heart condition

None

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Current medications* This field is required.

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Allergies* This field is required.

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Information from someone who knew you well (especially in childhood) can improve diagnostic accuracy.

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Is collateral information available?* This field is required.

Yes – childhood informant (e.g. parent)

Yes – adult informant (e.g. partner)

Both

No

55

Informant details

Full Name

Contacts email

Contacts phone

Consent to contact

56

Final declaration* This field is required.

Information provided is accurate to the best of my knowledge

I understand diagnosis is based on clinical assessment, not this form

I understand assessment may require more than one session

I understand that fees are payable in full prior to the appointment

I understand that paying the fee does not guarantee a diagnosis or medication

I consent to WeCare collecting and using this information for clinical care