• Adult ADHD Childhood Collateral Form

    Please answer based on your recollection of the patient's childhood behavior before age 12. Fill out all relevant sections and submit when done.
  • Please answer based on your own observations of the patient’s behavior as a child, before age 12—not the patient’s own answers. If you are unsure about an item, leave it blank. This form should be completed by someone who knew the patient well during childhood, such as a parent or family member.

  • Patient and Respondent Information

  • Patient Date of Birth*
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  • Today’s Date*
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  • Wender Utah Rating Scale (Observer Version)

  • Was the child restless or fidgety?*
  • Did the child have trouble sitting still?*
  • Did the child have difficulty sustaining attention?*
  • Was the child easily distracted?*
  • Did the child have trouble concentrating?*
  • Was the child impulsive?*
  • Did the child act before thinking?*
  • Did the child have trouble waiting turn?*
  • Did the child interrupt others?*
  • Was the child disorganized?*
  • Did the child have difficulty following instructions?*
  • Did the child forget things easily?*
  • Did the child lose things needed for tasks or activities?*
  • Was the child messy or careless in schoolwork?*
  • Did the child have trouble completing schoolwork?*
  • Was the child emotionally sensitive?*
  • Did the child have temper outbursts?*
  • Was the child moody or prone to mood swings?*
  • Did the child have trouble getting along with peers?*
  • Did the child have trouble getting along with adults?*
  • Was the child stubborn or oppositional?*
  • Did the child have low self-confidence?*
  • Did the child have trouble with transitions or changes in routine?*
  • Did the child appear overactive?*
  • Did the child seem immature for age?*

  • Childhood ADHD Symptom Checklist

  • Please rate the following observed childhood behaviors as they were before age 12.
  • Had difficulty sustaining attention during tasks or play
  • Seemed not to listen when spoken to directly
  • Did not follow through on instructions or failed to finish schoolwork or chores
  • Had difficulty organizing tasks or activities
  • Avoided or disliked tasks that required sustained mental effort
  • Lost things needed for activities such as school materials, toys, or homework
  • Was easily distracted by noises, activity, or other stimuli
  • Was fidgety, restless, or had trouble staying seated
  • Talked excessively, interrupted others, or had difficulty waiting a turn

  • Childhood Functional Impairment

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  • Should be Empty: