Childhood ADHD Collateral Questionnaire
Please complete this questionnaire to provide information about the child's behaviors and attention patterns. Your observations will assist in the assessment process.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Full Name
*
First Name
Last Name
Your Relationship to the Child
*
Please Select
Parent/Guardian
Teacher
Relative
Other
How long have you known the child?
*
Please Select
Less than 6 months
6-12 months
1-3 years
More than 3 years
In what settings do you observe the child? (Select all that apply)
*
Home
School
Extracurricular activities
Other
Please rate how often the child exhibits the following behaviors over the past 6 months:
*
Rows
Never
Rarely
Sometimes
Often
Very Often
Fails to give close attention to details or makes careless mistakes
1
2
3
4
5
Has difficulty sustaining attention in tasks or play activities
6
7
8
9
10
Does not seem to listen when spoken to directly
11
12
13
14
15
Does not follow through on instructions and fails to finish tasks
16
17
18
19
20
Has difficulty organizing tasks and activities
21
22
23
24
25
Avoids or dislikes tasks that require sustained mental effort
26
27
28
29
30
Loses things necessary for tasks or activities
31
32
33
34
35
Is easily distracted by extraneous stimuli
36
37
38
39
40
Is forgetful in daily activities
41
42
43
44
45
Fidgets with hands or feet or squirms in seat
46
47
48
49
50
Leaves seat in situations when remaining seated is expected
51
52
53
54
55
Runs about or climbs excessively in inappropriate situations
56
57
58
59
60
Has difficulty playing or engaging in leisure activities quietly
61
62
63
64
65
Is often "on the go" or acts as if "driven by a motor"
66
67
68
69
70
Talks excessively
71
72
73
74
75
Blurts out answers before questions have been completed
76
77
78
79
80
Has difficulty awaiting turn
81
82
83
84
85
Interrupts or intrudes on others
86
87
88
89
90
How much do these behaviors interfere with the child's daily functioning?
*
Not at all
A little
Moderately
Quite a bit
Extremely
Are there any other concerns or observations you would like to share about the child's behavior or attention?
Submit Questionnaire
Should be Empty: