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Adult ADHD Childhood Collateral Questionnaire

For a parent, relative, teacher, or anyone else who knew the patient before age 12. Your memories help our clinicians complete a thorough adult ADHD evaluation.

About 10 minutes 36 questions Auto-saves as you go

Before you begin

  • ✓You were named as someone who knew the patient as a child. Please answer only from what you personally remember before age 12.
  • ✓If you don't remember or never saw a behavior, choose "Can't recall / not observed."
  • ✓This questionnaire is one part of the evaluation. It does not diagnose ADHD on its own.
💾 Your answers are saved on this device as you type, so you can leave and come back to finish later.
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A

Patient Information

1.Patient's full name*
2.Patient's date of birth*
B

About You

3.How are you related to the patient?*
4.Did you know the patient well, or see them regularly, before they turned 12?*
5.Which part of the patient's childhood can you remember?*
Select all that apply
6.How sure are you about your memories of the patient before age 12?*
C

Attention & Organization Before Age 12How often did the child show each behavior?

7.Made careless mistakes or overlooked details in schoolwork, chores, or play.*
8.Struggled to keep attention on homework, reading, lessons, games, or conversations.*
9.Often seemed not to be listening when someone spoke to them directly.*
10.Began homework, chores, or tasks but often left them unfinished unless reminded or supervised.*
11.Had trouble organizing schoolwork, belongings, activities, or responsibilities.*
12.Avoided, put off, or disliked tasks that needed sustained mental effort, such as homework or reading.*
13.Often lost things needed for school or activities (books, homework, supplies, clothing, toys).*
14.Was easily pulled off task by sights, sounds, or activity nearby.*
15.Was often forgetful about assignments, chores, instructions, or things to bring.*
D

Activity Level & Impulsivity Before Age 12How often did the child show each behavior?

16.Fidgeted, tapped hands or feet, squirmed, or found it hard to sit still.*
17.Left their seat when expected to stay seated (class, meals, services, etc.).*
18.Ran about or climbed when it wasn't appropriate, or seemed unusually restless.*
19.Had trouble playing or doing leisure activities quietly.*
20.Seemed always "on the go" and hard to slow down.*
21.Talked much more than other children their age.*
22.Blurted out answers before questions were finished.*
23.Had trouble waiting for their turn.*
24.Interrupted or intruded on other people's conversations, games, or activities.*
E

Impact Before Age 12

25.Did these behaviors cause problems in any of these areas before age 12?*
Select all that apply
26.In which settings did you notice these behaviors?*
Select all that apply
27.Compared with children of a similar age, these behaviors were:*
28.At what age do you first remember clear problems with attention, organization, activity level, or impulsivity?*
F

School History

29.Do you remember any of the following from before or around age 12?*
Select all that apply
30.Did teachers or other adults often describe the child as:*
Select all that apply
31.Might any childhood records still be available?*
Select all that apply
G

Other Childhood Factors

32.During childhood, were any of these present that could have affected attention, behavior, learning, or school?*
Select all that apply
H

Overall Childhood Impression

33.Overall, before age 12, did the patient have ongoing problems with attention, organization, forgetfulness, high activity, or impulsivity?*
34.If so, how much did these problems affect the child's day-to-day functioning?*
35.As far as you remember, did these behaviors last for at least about 6 months?*
I

Additional InformationOptional

36.Is there anything else about the patient's childhood attention, behavior, school, or development that we should know?
✎

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Thank you for completing this questionnaire

Your responses were sent securely to the IC Health Services care team and will be reviewed as part of the patient's evaluation. Your saved draft has been cleared from this device.

This questionnaire gathers observations from people who knew the patient before age 12. It supports a comprehensive adult ADHD evaluation and does not, on its own, confirm or rule out an ADHD diagnosis. Questions? Call (443) 620-3616.

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