ADHD Diagnostic Assessment (NICHQ) - Parent Informant

Assessment 1 of 61

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

Secure

Your data is fully encrypted.

Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys assignments, pencils, books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. He or she is “on the go” or often acts as if “driven by a motor”
11. He or she Interrupts or intrudes in on others conversations and/or activities
12. Fidgets with hands or feet or squirms in seat
13. Leaves seat when remaining seated is expected
14. . Runs about or climbs too much when remaining seated is expected
15. Has difficulty playing or beginning quiet play activities
16. Talks too much
17. Blurts out answers before questions have been completed
18. Has difficulty waiting his or her turn
19. Is touchy or easily annoyed by others
20. Actively defies or refuses to go along with adults requests or rules
21. Argues with adults
22. Loses temper
23. Deliberately annoys people
24. Blames others for his or her mistakes or misbehaviors
25. Is angry or resentful
26. Is spiteful and wants to get even
27. Lies to get out of trouble or to avoid obligations
28. Deliberately destroys others property
29. He or she has broken into someone elses home, business, or car
30. Bullies, threatens, or intimidates others
31. Starts physical fights
32. Is truant from school (skips school) without permission
33. Is physically cruel to people
34. Has stolen things that have value
35. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
36. Is physically cruel to animals
37. Has deliberately set fires to cause damage
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Feels lonely, unwanted, or unloved; complains that no one loves him or her
42. Is fearful, anxious, or worried
43. Is afraid to try new things for fear of making mistakes
44. Feels worthless or inferior
45. . Blames self for problems, feels guilty
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed
48. Reading
49. Writing
50. Mathematics
51. Relationship with parents
52. Relationship with siblings
53. Relationship with peers
54. Relationship with peers
55. Participation in organized activities (eg, teams)
56. Motor Tics: Rapid, repetitive movements such as eye blinking, grimacing, nose twitching, head jerks, shoulder shrugs, arm jerks, body jerks, or rapid kicks
57. Phonic (Vocal) Tics: Repetitive noises including but not limited to throat clearing, coughing, whistling, sniffing, snorting, screeching, barking, grunting, or repetition of words or short phrases.
58. If YES to 1 or 2, do these tics interfere with the childs activities (like reading, writing, walking, talking, or eating)?