Informant Questionnaire
Adult ADHD assessment informant questionnaire. Please complete all items in the same order as the source document.
Informant and individual details
Today’s date
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Month
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Day
Year
Date
Your name
*
Name of individual
*
Relationship to individual
*
Parent
Sibling
Other
If 'Other', how long have you known them?
Your home address
*
Postcode
*
Your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your email address
*
example@example.com
Reason for referral / main difficulties
What do you feel are this person’s main difficulties in relation to inattention, hyperactivity, impulsivity?
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When were you aware of these starting?
*
Education and employment
Please outline any exam results or qualifications they achieved.
Did they need any additional support in school, college, or university? If yes, what types of difficulties did they have and what support was offered?
Did school present any challenges? If so, what were they?
Have they had any problems in getting or keeping a job? If yes, what have been the problems?
Daily living skills
How does the person plan and prioritise tasks and activities at home?
Can you describe how forgetfulness affects their daily life?
What aspects of daily life do they manage successfully?
Physical and mental health
Has the person received a diagnosis of ADHD?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Autism?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Learning disability?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Dyslexia?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Epilepsy?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Tourettes?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Dyspraxia?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Has the person received a diagnosis of Dyscalculia?
Yes
No
Unknown
Unsure
If yes, year of diagnosis
Does the person have any physical health problems or allergies?
Have they ever had a head injury? If yes, please provide details.
Have they ever had any mental health problems? Please outline what these are and if they needed treatment.
Did they see any mental health professionals during childhood (other than a GP)? If so, please give details.
Has anyone in their family ever had any mental health problems or a diagnosis of ADHD?
Infancy and early childhood history
Were there any problems related to the pregnancy? If yes, please describe.
Were there any problems related to birth? If yes, please describe.
What were they like as a baby (sleep, feeding, behaviour etc)?
Compared with children their age, were they late in reaching any of their developmental milestones?
If you are able to recall, what age did they start walking?
If you are able to recall, what age did they start talking?
If you are able to recall, what age did they start toilet training?
Were any issues identified in pre-school or nursery – your perception and/or any teacher observations?
School age
Were any issues identified in school (infant, junior and secondary) – your perception and/or any teacher observations?
What was the person’s experience of secondary school like?
As a child, compared to other children, were they quiet or did they talk too much?
Was their behaviour the same at home as it was at school?
How were they at following instructions?
Did they follow instructions in the same way at home and school?
How did they engage in school? How did others describe them?
How did they manage homework and meeting deadlines? If unable to, please describe why.
How do they manage starting and completing activities?
How did they engage socially, both in and out of school?
What type of comments would their teachers give during parent-teacher evenings and in report cards?
Adulthood, relationships, and social functioning
As an adult, how do they manage their friendships and relationships?
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How easy is it to have a conversation and engage with this person? Does it feel balanced, or one-sided and on their terms?
*
How would others who know them well (friends, family, colleagues) describe them?
*
Risk-related behaviours
Have they ever been in trouble with the police?
Do they consume illicit substances? If so, from what age?
Do they seek thrill and engage in dangerous activities? If so, please describe.
Submit
Should be Empty: