• 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.

  • Patient and Respondent Information

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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: