Adult ADHD Background Information

Questionnaire

Please fill out the following form to help us understand your condition.

First Name

Email Address

Last Name

Date of Birth

Address

Town

Mobile Phone

Land Line

GP Practice

Other significant contacts/ persons involved

Who do you live with?

Who was at home when you were a child?

Do you have any brothers or sisters?

Does anyone in your family have a history/diagnosis of any developmental conditions such as autism or ADHD, or any learning disability or psychiatric disorder?

Were you born

Early

Late

On time

If early or late, do you know how many weeks?

Do you know your birth weight?

Were there any complications at your birth?

Were you a healthy baby?

What was your behaviour like as a baby/toddler? Tick the descriptions which apply.

High activity level

Impulsive

Accident prone

Short attention span

Sleep problems

Temper tantrums

Colic

Eating problems

Clumsy

Did you reach your developmental milestones (crawling, walking, talking etc) at an average age? Was there anything unusual about your milestones? Any other important information about your early years?

Did you attend nursery? Were there any difficulties?

Did you attend primary school? Were there any difficulties?

Did you attend secondary school? Were there any difficulties? Did you receive any special help?

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Adult ADHD Background Information

Questionnaire

Please fill out the following form to help us understand your condition.

First Name

Email Address

Last Name

Date of Birth

Address

Town

Post Code

Mobile

GP Practice

Other significant contacts/ persons involved

Who do you live with?

Who was at home when you were a child?

Do you have any brothers or sisters?

Does anyone in your family have a history/diagnosis of any developmental conditions such as autism or ADHD, or any learning disability or psychiatric disorder?

Were you born

Early

Late

On time

If early or late, do you know how many weeks?

Do you know your birth weight?

Were there any complications at your birth?

Were you a healthy baby?

What was your behaviour like as a baby/toddler? Tick the descriptions which apply.

High activity level

Impulsive

Accident prone

Short attention span

Sleep problems

Temper tantrums

Colic

Eating problems

Clumsy

Did you attend nursery? Were there any difficulties?

Did you attend primary school? Were there any difficulties?

Did you attend secondary school? Were there any difficulties? Did you receive any special help?

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Adult ADHD Background Information

Questionnaire

Please fill out the following form to help us understand your condition.

Have you been asked by us to complete this form?

Yes

First Name

Email Address

Last Name

Date of Birth

Address

Town

Post Code

Mobile

Land Line

GP Practice

Significant others that you might like to ask to attend a consultation with you.

Who do you live with?

Who was at home when you were growing up?

Do you have any brothers or sisters?

Does anyone in your family have a history/diagnosis of any developmental conditions such as autism or ADHD, or any learning disability or psychiatric disorder?

Were you born

Early

Late

On time

If born early or late, do you know how many weeks you were?

Do you know your birth weight (in pounds)?

Were there any complications at your birth?

Were you a healthy baby?

What was your behaviour like as a young child? Tick any that apply

High activity level

Impulsive

Accident prone

Short attention span

Sleep problems

Eating problems

Clumsy

Colic

Temper tantrums

Was there anything unusual about your developmental milestones (crawling, walking, talking)? Any other important information about your early years?

Did you attend nursery?

Yes

Did you attend primary school?

Were there any difficulties?

Did you attend secondary school?

Were there any difficulties?

Were you bullied in school?

Did you truant from school?

Did you have a statement of special educational needs?

Did you attend a special needs school?

What age were you when you left school?

Were you ever suspended or expelled?

Yes

How many times?

What age were you?

Did you receive any further education at college or university?

Yes

What did you study?

What are your educational qualifications, for example GCSE, A-Level, Degree etc?

What is your current job?

How many jobs have you had?

What is the longest period of time that you have spent in one job?

What was your best job?

Do you have any particular difficulties holding down jobs?

Yes

How many times have you resigned, and why?

How many times have you been fired, and why?

Any other important information about your occupational history?

Are there any difficulties making or keeping friendships?

Are you currently in a relationship?

How many previous relationships have you had?

Do you have any children

Yes

What are their names and ages?

Do any of them have ADHD?

What are your hobbies and interests?

Have you passed your driving test?

Yes

Do you have any driving convictions (speeding, drink driving etc)?

Have you ever been in trouble with the police?

Yes

Any cautions?

Have you ever served a prison sentence or been under probation services

Physical health: have you had any significant illnesses?

Physical health: are there any problems for which you need to see your GP regularly?

Do you have any history of heart disease?

Yes

Please give details

Is there any family history of heart problems?

Have you ever been diagnosed with ADHD?

Have you ever been diagnosed with any other mental health problem?

Have you ever self harmed?

Do you ever have thoughts of self-harm or suicide?

How many cups of tea and coffee do you drink a day?

Do you smoke?

Yes

How many cigarettes do you smoke?

Weekly spend?

Do you drink alcohol

Yes

How much alcohol do you drink/wk?

Weekly spend?

Have you ever tried any illegal drugs?

Yes

Cannabis

No never tried it

Yes, tried it in the past

Yes, currently using

If yes, please provide details

Amphetamines (speed)

No never tried it

Yes, tried it in the past

Yes, currently using

Ecstacy (pills, E's)

No never tried it

Yes, tried it in the past

Yes, currently using

Cocaine (coke)

No never tried it

Yes, tried it in the past

Yes, currently using

Crack cocaine

No never tried it

Yes, tried it in the past

Yes, currently using

Heroin smoked

No never tried it

Yes, tried it in the past

Yes, currently using

Heroin injected

No never tried it

Yes, tried it in the past

Yes, currently using

LSD/Acid

No never tried it

Yes, tried it in the past

Yes, currently using

Magic mushrooms

No never tried it

Yes, tried it in the past

Yes, currently using

Ketamine

No never tried it

Yes, tried it in the past

Yes, currently using

How would you describe yourself?

How would others describe you?

Have you any particular goals, or things you would like to change?

Today's Date

Thanks for submitting!

Haydock Medical Centre

Woodside Rd, Haydock, St Helens, WA11 0NA

Adult ADHD Background Information

Questionnaire

Adult ADHD Background Information

Questionnaire

Adult ADHD Background Information

Questionnaire