Haydock ADHD Service

Self-rating scales

Your Details

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Family History

Who was at home when you were a child?

Do you have any brothers and sisters? Details:

Does anyone in your family have a history/diagnosis of any developmental conditions/ autism/ADHD/ learning disability/psychiatric disorder? Details:

Birth History and Early Development

Were you born:

Were there any complications at your birth?

Were you a healthy baby? Details:        

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

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?

Education

Nursery: did you attend nursery. Were there any difficulties?

Primary School: did you attend primary school. Were there any difficulties? Did you receive any special help?

Secondary School: did you attend secondary school. Were there any difficulties? Did you receive any special help?

Were you bullied in school? Did you every truant from school?

Did you have a statement of special educational needs?

Did you attend a special needs school?

How old were you when you left school?

Were you suspended or expelled from school?

Did you receive any further education at college or University? If yes, what did you study?

What are your educational qualifications? GCSE/ A-Level / Degree etc?

Any other significant events in your education?

Occupation

What is your current job?

How many jobs have you had?

What is the longest period you ever spent in one job?

What was your best job?

Do you have any particular difficulties holding down jobs?

How many times have you resigned? Reasons?

How many times have you ben fired? Reasons?

Any other important information from your occupational history?