Blockhouse Bay Medical CentreBlockhouse Bay Medical Centre
Bethells Beach on Auckland's west coast

Private clinical intake

ADHD Questionnaire

01

Personal details

Details used to match the questionnaire to the correct patient record.

02

General health and background

Were there concerns about your early development, language, learning, coordination, or progress at school?
Do you have a significant medical or neurological history, such as seizures, head injury, thyroid problems, heart disease, or another long-term condition?
Do you currently take prescribed or non-prescribed medicines or supplements, or have any medication allergies?
Have you previously experienced mental-health difficulties, diagnoses, treatment, hospital care, self-harm, unusually elevated mood, or loss of contact with reality?
Do you have ongoing sleep problems, such as difficulty falling or staying asleep, excessive sleepiness, snoring, or suspected sleep apnoea?
Do you currently use alcohol, nicotine or vapes, cannabis, non-prescribed stimulants, or other recreational substances?
Is there a family history of ADHD, autism, learning differences, or significant mental-health conditions?
03

Symptoms

For each symptom, rate how often it applied as a child by age 12 and in the past few months or years. An example box appears only after Sometimes or Often is selected.

Choose one answer for every childhood and recent rating.

Where possible, think of concrete situations rather than your general impression.

C1. As a child (by age 12): Did you fail to give close attention to details or make careless mistakes (e.g. difficulty focusing on schoolwork, tasks or chores)?
P1. In the past few months or years: Have you failed to give close attention to details or made careless mistakes (e.g. difficulty focusing on work, tasks or chores)?
C2. As a child (by age 12): Did you fail to sustain attention in tasks or activities (e.g. maintaining your focus over a long period when concentrating on tasks)?
P2. In the past few months or years: Have you failed to sustain attention in tasks or activities (e.g. maintaining your focus over a long period when concentrating on tasks)?
C3. As a child (by age 12): Did you not listen to what was being said to you (e.g. difficulty concentrating on what people said to you, even when being spoken to directly)?
P3. In the past few months or years: Have you not listened to what is being said to you (e.g. difficulty concentrating on what people say, even when being spoken to directly)?
C4. As a child (by age 12): Did you fail to follow through on instructions or finish tasks (e.g. not completing chores or schoolwork, taking “short-cuts” and missing things out)?
P4. In the past few months or years: Have you failed to follow through on instructions or finish tasks (e.g. not completing work, taking “short-cuts” and missing things out)?
C5. As a child (by age 12): Did you struggle to organise tasks and activities (e.g. difficulty structuring and planning tasks on your own, missing deadlines)?
P5. In the past few months or years: Have you struggled to organise tasks and activities (e.g. difficulty structuring and planning tasks on your own, missing deadlines)?
C6. As a child (by age 12): Did you avoid or strongly dislike tasks requiring sustained mental effort (e.g. by delaying or reluctantly starting tasks that took a lot of thought)?
P6. In the past few months or years: Have you avoided or strongly disliked tasks requiring sustained mental effort (e.g. a delay or reluctance to start tasks that take a lot of thought)?
C7. As a child (by age 12): Did you lose things necessary for certain tasks or activities (e.g. misplaced or had difficulty finding things you needed at home or school)?
P7. In the past few months or years: Have you lost things necessary for certain tasks or activities (e.g. misplaced or had difficulty finding things you need at home or work)?
C8. As a child (by age 12): Were you easily distracted by your own thoughts or by things going on around you (e.g. by daydreaming, noise or activities)?
P8. In the past few months or years: Have you been easily distracted by your own thoughts or by things going on around you (e.g. by daydreaming, noise or activities)?
C9. As a child (by age 12): Were you forgetful in your daily activities (e.g. forgetting items you needed for activities or things you must do)?
P9. In the past few months or years: Have you been forgetful in your daily activities (e.g. forgetting items you need for activities, forgetting appointments or meetings)?
C10. As a child (by age 12): Did you fidget with your hands or feet or squirm about when sitting down (e.g. could not sit still, wriggling in your chair, fiddling with items, distracting others)?
P10. In the past few months or years: Have you felt restless or fidgety (e.g. unable to settle, fidgeting with hands, legs or feet, fiddling with items, distracting others)?
C11. As a child (by age 12): Did you leave your seat in situations you were expected to remain seated (e.g. in class, places of worship, on public transport or at the cinema)?
P11. In the past few months or years: Have you left your seat in situations where you were expected to remain seated (e.g. in meetings at work, places of worship, the cinema)?
C12. As a child (by age 12): Were you hyperactive (e.g. overly active, running in roads and corridors, climbing things without considering your own or others’ safety)?
P12. In the past few months or years: Have you felt restless or physically agitated inside (e.g. feeling a constant need to be active, pacing, struggling to unwind, settle or relax)?
C13. As a child (by age 12): Did you have difficulty engaging quietly in leisure activities (e.g. could not settle, play or work quietly on your own)?
P13. In the past few months or years: Have you had difficulty engaging quietly in leisure activities (e.g. cannot settle to work, read or watch TV)?
C14. As a child (by age 12): Were you persistently active and “on the go” (e.g. always rushing around, like a whirlwind, could not switch off)?
P14. In the past few months or years: Have you been persistently active, busy and “on the go” (e.g. have to be busy, excessively driven, doing things at a frantic pace, cannot switch off)?
C15. As a child (by age 12): Did you interrupt others who were speaking (e.g. talking over people, impatiently blurting out thoughts or answers, not waiting your turn to speak)?
P15. In the past few months or years: Have you interrupted others who were speaking (e.g. talking over people, finishing their sentences, not waiting your turn to speak)?
C16. As a child (by age 12): Were you so impatient that you impulsively acted without thought of the consequences of that behaviour (e.g. queue jumping, fighting, spending money)?
P16. In the past few months or years: Have you been so impatient that you have acted impulsively without thought of the consequences of that behaviour (e.g. spending money)?
C17. As a child (by age 12): Did you interrupt or intrude on others (e.g. on conversations, personal or private space or activities of others, not adhering to social boundaries)?
P17. In the past few months or years: Have you interrupted or intruded on others (e.g. on conversations, private space or activities of others, not adhering to social boundaries)?
C18. As a child (by age 12): Did you talk excessively even at times when this was inappropriate (e.g. without constraint, persistent chattering, dominating conversation)?
P18. In the past few months or years: Have you talked excessively even when this is inappropriate (e.g. without constraint, persistent chattering, dominating conversation)?

ACE+SRv2 © Psychology Services Limited 2024. Used with permission.

04

Onset, persistence, and functional effect

20. Have these symptoms or problems been present and caused you difficulties over the past six months? *
05

PHQ-9

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed; or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way

If you may act on these thoughts or cannot keep yourself safe, call 111 now or go to the nearest emergency department. This form is not monitored continuously.

06

GAD-7

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen
07

Check and submit

Your responses are sent to the practice for clinician review. Scores and their screening meanings are calculated securely after submission and are not a diagnosis.

Payment by bank transfer

Initial ADHD consultation

There is no cost to submit this questionnaire. Use these details when paying for the one-hour in-person consultation.

$560
Account
03 0118 0039517 - 00
Account name
BLOCKHOUSE BAY MEDICAL CENTRE
Particulars
First-name initial + full last name, e.g. B DYLAN
Code
ADHD
Reference
Dr Kierrtana
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