ADHD Informant and Collateral History Form

This form will assist in the ADHD assessment of your family member, friend or spouse. Depending on how long you have known the person being assessed for ADHD, you will be asked about your observations of them in childhood and/or adulthood. Please allow 10-15 minutes to complete this form.

Please note the information you provide can only be accessed by your psychiatrist. It is stored securely according to Australian privacy legislation and all data is encrypted. If you would prefer to have a paper form to be mailed out to you instead, please contact Pax Centre reception on (08) 9455 5440

Patient Details

First name of patient *

Last name of patient *

Informant's details

Please provide your details below. You will then be asked to provide the details of the person being assessed for ADHD.

Phone Number *

Email address

Do you consent to the psychiatrist contacting you by phone to discuss your responses about the person being assessed for ADHD (if required)? *

YesNo

Have you known this person since they were a child, or since adulthood? *

Since they were a childSince they were an adult

If you selected "since they were a child" please skip the "DIVA-5 Adult questions" - to do to this you will just have to select "No, none of the examples were applicable" in each row.
If you selected "since they were an adult" please skip the "DIVA-5 Childhood questions" - to do to this you will just have to select "No, none of the examples were applicable" in each row.

Please estimate how long you have known them for: *

I understand filling in this form is optional and I consent to completing this ADHD screening form. If you agree with this statement, please select 'I agree': *

Your name and relationship to patient eg. John Smith, Father *

Office Use Only

Childhood Attention Score - DIVA (Office Only)

Childhood Hyperactivity Score - DIVA (Office Only)

Adult Attention Score - DIVA (Office Only)

Adult Hyperactivity Score - DIVA (Office Only)

DIVA-5 Childhood Questions

Childhood - Inattention Symptoms

For each question, please consider whether the person being assessed had these symptoms between the age of 5yrs and 12yrs. Please provide examples if you can think of any, as this supports the answer

Child A2. Did they often have difficulty sustaining their attention in tasks? Please tick all that apply:

Difficulty keeping attention on schoolworkDifficulty keeping attention on play (do not select this if they found it to be really interesting, eg computer game or hobby)Difficulty remaining focused during conversations or when teacher was trying to teach the classEasily distractedDifficulty concentrating Needing structure to avoid becoming distractedQuickly became bored of activities

Child A2.1: Did you tick AT LEAST ONE example in the previous question (Child A2)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A2.2: If you ticked NONE of the examples in the previous question (Child A2) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A3. Did it seem as though they were not listening when they were spoken to directly?

Not knowing what parents/teachers have saidDreamy or preoccupiedOnly listening during eye contact or when a voice was raisedMind seemed elsewhere, even in the absence of any obvious distractionOften having to be addressed againQuestions having to be repeated

Child A3.1: Did you tick AT LEAST ONE example in the previous question (Child A3)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A3.2: If you ticked NONE of the examples in the previous question (Child A3) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A4. Did they often not follow through on instructions and often fail to finish chores or duties at school or at home?

Difficulty following instructionsDifficulty with instructions involving more than one step Started tasks but quickly lost focus and was easily sidetrackedNot completing thingsNot completing homework or handing it inNeeded a lot of structure in order to complete tasks

Child A4.1: Did you tick AT LEAST ONE example in the previous question (Child A4)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A4.2: If you ticked NONE of the examples in the previous question (Child A4) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A6. Did they often avoid (or did they dislike / were reluctant to engage in) tasks that require sustained mental effort?

Avoidance of homework or had an aversion to thisRead few books or did not feel like reading due to mental effortAvoidance of tasks that require a lot of concentrationAversion to school subjects that require a lot of concentration Often postponed boring or difficult tasks

Child A6.1: Did you tick AT LEAST ONE example in the previous question (Child A6)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A6.2: If you ticked NONE of the examples in the previous question (Child A6) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A7. Did they often lose things that were necessary for tasks or activities?

Losing their school materials, pencils, books, or other itemsMislaying toys, clothing or homeworkSpent a lot of time searching for thingsGot in a panic if other people moved things aroundComments from parents and/or teacher about things being lost

Child A7.1: Did you tick AT LEAST ONE example in the previous question (Child A7)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A7.2: If you ticked NONE of the examples in the previous question (Child A7) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A8. Were they often distracted by external stimuli?

In the classroom, often looking outsideEasily distracted by noises or eventsAfter being distracted, had difficulty picking up the thread again

Child A8.1: Did you tick AT LEAST ONE example in the previous question (Child A8)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A8.2: If you ticked NONE of the examples in the previous question (Child A8) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child A9. Were they often forgetful in daily activities?

Forgot appointments or instructionsForgot to do chores or run errandsHad to be frequently reminded of thingsHalf-way through a task, forgetting what has to be doneForgot to take things to school Leaving things behind at school or at a friend's house

Child A9.1: Did you tick AT LEAST ONE example in the previous question (Child A9)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child A9.2: If you ticked NONE of the examples in the previous question (Child A9) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Childhood - Hyperactive & Impulsive Symptoms

Child H1. Did they often fidget with or tap hands or feet, or did they often squirm in their seat?

Parents often said 'sit still' or similarFidgeted with the legsTapping with a pen or playing with somethingFiddling with hair or biting nailsUnable to remain seated in a chair in a relaxed mannerAble to control restlessness but felt stressed as a result

Child H1.1: Did you tick AT LEAST ONE example in the previous question (Child H1)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H1.2: If you ticked NONE of the examples in the previous question (Child H1) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H2. Did they often leave your seat in situations where they were expected to remain seated?

Often stood up while eating or left their place in the classroomFound it very difficult to stay seated at school or during mealsBeing told to remain seatedMade excuses in order to walk around

Child H2.1: Did you tick AT LEAST ONE example in the previous question (Child H2)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H2.2: If you ticked NONE of the examples in the previous question (Child H2) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H3. Did they often feel restless?

Always running around where it was not appropriateClimbing on furniture, or jumping on the sofaClimbing in treesFeeling restless inside

Child H3.1: Did you tick AT LEAST ONE example in the previous question (Child H3)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H3.2: If you ticked NONE of the examples in the previous question (Child H3) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H4. Did they often find it difficult to engage in leisure activities quietly?

Being loud-spoken during play or in the classroomUnable to watch TV or movies quietlyAsked to be quieter or calm down Becoming quickly too cocky in public

Child H4.1: Did you tick AT LEAST ONE example in the previous question (Child H4)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H4.2: If you ticked NONE of the examples in the previous question (Child H4) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H5. Were they often 'on the go' or did they often act as if 'driven by a motor'?

Constantly busyOthers found them restless or difficult to keep up withWas uncomfortable being still for an extended timeExcessively active at school and at homeHad lots of energyAlways on the go, excessively driven

Child H5.1: Did you tick AT LEAST ONE example in the previous question (Child H5)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H5.2: If you ticked NONE of the examples in the previous question (Child H5) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H6. Did they often talk excessively?

Known as a chatterboxTeachers and parents often asked them to be quietComments in school reports about talking too much Being punished for talking too much Kept others from doing schoolwork by talking too much Not giving others room during a conversation

Child H6.1: Did you tick AT LEAST ONE example in the previous question (Child H6)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H6.2: If you ticked NONE of the examples in the previous question (Child H6) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H7. Did they often blurt out an answer before questions had been completed?

Being a blabbermouth, saying things without thinking firstWanted to be the first to answer questions at school Blurted out an answer even if it is wrongInterrupted others before sentences are finishedDifficulty waiting turn during conversationsComing across as being tactless

Child H7.1: Did you tick AT LEAST ONE example in the previous question (Child H7)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H7.2: If you ticked NONE of the examples in the previous question (Child H7) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H8. Did they often find it difficult to wait their turn?

Difficulty waiting turn in group activitiesDifficulty waiting turn in the classroomAlways being the first to talk or actBecame impatient quickly Crossed the road without looking

Child H8.1: Did you tick AT LEAST ONE example in the previous question (Child H8) *

Yes, I ticked at least one example No, none of the examples were applicable

Child H8.2: If you ticked NONE of the examples in the previous question (Child H8) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Child H9. Did they often interrupt or intrude on others?

Interrupted the games or activities of othersStarted using people's things without asking Interrupted the conversations of othersReacted to everything Unable to wait

Child H9.1: Did you tick AT LEAST ONE example in the previous question (Child H9)? *

Yes, I ticked at least one example No, none of the examples were applicable

Child H9.2: If you ticked NONE of the examples in the previous question (Child H9) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

DIVA-5: Adulthood Questions

The following questions assess the person's symptoms as an adult. Please consider their symptoms for the last SIX MONTHSwhen responding to each question.

Adulthood: Inattention Symptoms

Adult A2. Do they often have difficulty sustaining their attention in tasks?

Not able to keep attention on tasks for long (unless it is an interesting topic or hobby)Quickly distracted by own thoughts or associationsEasily distracted by unrelated thoughtsDifficulty remaining focused during lectures and/or conversationsFinds it difficult to watch a film through to the end, or to read a book (unless it is an interesting topic or hobby)Quickly becomes bored with things (unless it is an interesting topic or hobby)Asks questions about subjects that have already been discussed

Adult A2.1: Did you tick AT LEAST ONE example in the previous question (Adult A2)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult A2.2: If you ticked NONE of the examples in the previous question (Adult A2) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult A4. Do they often not follow through on instructions and often fail to finish chores or duties in the workplace or in their studies?

Does things that are muddled up together without completing themStarts tasks but quickly loses focus and is easily sidetrackedNeeding a time limit to complete tasksDifficulty completing administrative tasks Difficultly following instructions from a manual

Adult A4.1: Did you tick AT LEAST ONE example in the previous question (Adult A4)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult A4.2: If you ticked NONE of the examples in the previous question (Adult A4) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult A6. Do they often avoid (or do they dislike, or are they reluctant to engage in) tasks that require sustained mental effort?

Do the easiest or nicest things first of all Often postpone boring or difficult tasksPostpone tasks so that deadlines are missedAvoid monotonous work, such as administrationAvoids preparing reports, completing forms, or reviewing lengthy papersDo not like reading due to mental effort Avoidance of tasks that require a lot of concentration

Adult A6.1: Did you tick AT LEAST ONE example in the previous question (Adult A6)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult A6.2: If you ticked NONE of the examples in the previous question (Adult A6) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult A7. Do they often lose things that are necessary for tasks or activities?

Mislays tools, paperwork, eyeglasses, mobile telephones, wallet, keys, or agendaOften leaves things behind Loses papers for workLoses a lot of time searching for thingsGets in a panic if other people move things aroundStores things away in the wrong place Loses notes, lists or telephone numbers

Adult A7.1: Did you tick AT LEAST ONE example in the previous question (Adult A7)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult A7.2: If you ticked NONE of the examples in the previous question (Adult A7) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult A8. Are they often easily distracted by extraneous stimuli?

Difficulty shutting off from external stimuliAfter being distracted, difficult to pick up the thread againEasily distracted by noises or eventsEasily distracted by the conversations of others Difficulty in filtering and/or selecting information

Adult A8.1: Did you tick AT LEAST ONE example in the previous question (Adult A8)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult A8.2: If you ticked NONE of the examples in the previous question (Adult A8) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adulthood: Hyperactive / Impulsive Symptoms

The following questions assess the person's symptoms as an adult. Please consider their symptoms for the last SIX MONTHS when responding to each question.

Adult H1. Do they often fidget with or tap their hands or feet, or do they often squirm in their seat?

Difficulty sitting stillFidgets with the legsTapping with a pen or playing with somethingFiddling with hair or biting nailsAble to control restlessness, but feels stressed as a result

Adult H1.1: Did you tick AT LEAST ONE example in the previous question (Adult H1)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H1.2: If you ticked NONE of the examples in the previous question (Adult H1) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H2. Do they often leave their seat in situations where it is expected that they remain seated?

Often leaves his/her place in the office or in the workplaceAvoids symposiums, lectures, church etc.Prefers to walk around rather than sitNever sits still for long, always moving aroundStressed owing to the difficulty of sitting still Makes excuses in order to be able to walk around

Adult H2.1: Did you tick AT LEAST ONE example in the previous question (Adult H2)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H2.2: If you ticked NONE of the examples in the previous question (Adult H2) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H3. Do they often feel restless?

Feeling restless or agitated insideConstantly having the feeling that they have to be doing something Finding it hard to relax

Adult H3.1: Did you tick AT LEAST ONE example in the previous question (Adult H3)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H3.2: If you ticked NONE of the examples in the previous question (Adult H3) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H4. Do they often find it difficult to engage in leisure activities quietly?

Talks during activities when this is not appropriateBecoming quickly too cocky in publicBeing loud in all kinds of situationsDifficulty doing activities quietlyDifficultly in speaking softly

Adult H4.1: Did you tick AT LEAST ONE example in the previous question (Adult H4)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H4.2: If you ticked NONE of the examples in the previous question (Adult H4) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H5. Are they often “on the go” or do they often act as if “driven by a motor”?

Always busy doing somethingIs uncomfortable being still for extended time, e.g. in restaurants or meetingsHas too much energy, always on the moveOthers find them restless or difficult to keep up withStepping over their own boundariesFinds it difficult to let things go, excessively driven

Adult H5.1: Did you tick AT LEAST ONE example in the previous question (Adult H5)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H5.2: If you ticked NONE of the examples in the previous question (Adult H5) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H6. Do they often talk excessively?

So busy talking that other people find it tiringKnown to be an incessant talkerFinds it difficult to stop talkingTendency to talk too muchNot giving others room to interject during a conversationNeeding a lot of words to say something

Adult H6.1: Did you tick AT LEAST ONE example in the previous question (Adult H6)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H6.2: If you ticked NONE of the examples in the previous question (Adult H6) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H7. Do they often blurt out an answer before questions have been completed?

Being a blabbermouth, saying what they thinkSaying things without thinking firstGiving people answers before they have finished speakingCompleting other people’s sentencesBeing tactless

Adult H7.1: Did you tick AT LEAST ONE example in the previous question (Adult H7)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H7.2: If you ticked NONE of the examples in the previous question (Adult H7) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H8. Do they often find it difficult to await their turn?

Difficulty waiting in a queue, jumping the queueDifficulty in patiently waiting in the traffic/traffic jamsBeing impatientQuickly starting relationships/jobs, or ending/leaving these because of impatience

Adult H8.1: Did you tick AT LEAST ONE example in the previous question (Adult H8)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H8.2: If you ticked NONE of the examples in the previous question (Adult H8) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Adult H9. Do they often interrupt or intrude on others?

Being quick to interfere with othersIntrudes on othersDisturbs other people’s activities without being asked, or takes over their tasksComments from others about interferenceDifficulty respecting the boundaries of othersHaving an opinion about everything and immediately expressing this

Adult H9.1: Did you tick AT LEAST ONE example in the previous question (Adult H9)? *

Yes, I ticked at least one example No, none of the examples were applicable

Adult H9.2: If you ticked NONE of the examples in the previous question (Adult H9) but are aware of other examples not listed (or simply wish to add more detail), please comment here.

Additional Comments

In which areas of life have you noticed these symptoms having an impact on the persons functioning in the last SIX MONTHS? Please tick all that apply:

Family relationships and functioningWork performance / work relationshipsFriendships / social skillsRomantic relationshipsUniversity / TAFE / SchoolRisk taking behavioursSelf esteemActivities of daily living (housework, eating, exercise, running late, forgetting appointments and so on)

Please provide further details about the impact on their functioning (if you wish):

Do you have any other comments to add about their behaviour as a child?

Do you have any other comments to make about their behaviour as an adult?

Have their symptoms been present for as long as you have known them (even if they have fluctuated during this time)? * *

YesNo

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I declare that the above information is an honest account of the symptoms I have observed in the person being assessed for ADHD.

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