ADHD Pre-interview Form

Patient's Name:

First name *

Last name *

Name of GP

Name of GP clinic

Office only

ASRS Section A

ASRS Section B

Childhood Attention Score

Childhood Hyperactivity Score

Adult Attention Score

Adult Hyperactivity Score

WFIRS Family Score

WFIRS Life Skills Score

WFIRS Work Score

WFIRS School Score

WFIRS Self Concept Score

WFIRS Social Score

WFIRS Risk Score

Further Demographic Details

Date of Birth

Address

Phone Number *

Email address: *

DIVA - Childhood symptoms

For each question, please consider whether you had these symptoms between the age of 5yrs and 12yrs. Please provide examples if you can think of any, as this supports the answer. If you can think of an example that is not listed, please put this example in the comments section for each question.

Childhood - Attention Symptoms

Child A2. Did you often have difficulty sustaining your 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 becoming 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 you were not listening when you were spoken to directly?

Not knowing what parents/teachers have saidDreamy or preoccupiedOnly listening during eye contact or when a voice is raisedMind seems 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 you 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 Starts tasks but quickly loses focus and is easily sidetrackedNot completing thingsNot completing homework or handing it inNeeding 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 you often avoid (or did you dislike / were reluctant to engage in) tasks that require sustained mental effort?

Avoidance of homework or has an aversion to thisReads few books or does 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 postpones 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 you often lose things that were necessary for tasks or activities?

Loses school materials, pencils, books, or other itemsMislays toys, clothing or homeworkSpends a lot of time searching for thingsGets in a panic if other people move 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 you often distracted by external stimuli?

In the classroom, often looking outsideEasily distracted by noises or eventsAfter being distracted, has 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 you often forgetful in daily activities?

Forgets appointments or instructionsForgets to do chores or run errandsHas to be frequently reminded of thingsHalf-way through a task, forgetting what has to be doneForgets 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 and Impulsive Symptoms

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

Parents often said 'sit still' or similarFidgets 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 you often leave your seat in situations where you were expected to remain seated?

Often stands up while eating or leaves their place in the classroomFinds it very difficult to stay seated at school or during mealsBeing told to remain seatedMaking 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 you 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 you 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 you often 'on the go' or did you often act as if 'driven by a motor'?

Constantly busyOthers find them restless or difficult to keep up withIs uncomfortable being still for an extended timeExcessively active at school and at homeHas 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 you often talk excessively?

Known as a chatterboxTeachers and parents often ask them to be quietComments in school reports about talking too much Being punished for talking too much Keeping 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 you often blurt out an answer before questions had been completed?

Being a blabbermouth, saying things without thinking firstWants to be the first to answer questions at school Blurts out an answer even if it is wrongInterrupts 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 you often find it difficult to wait your turn?

Difficulty waiting turn in group activitiesDifficulty waiting turn in the classroomAlways being the first to talk or actBecomes quickly impatientCrosses 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 you often interrupt or intrude on others?

Interrupts the games or activities of othersStarts using people's things without asking Interrupts the conversations of othersReacts 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- Adulthood Symptoms

The following questions assess your symptoms in adulthood. Please consider your symptoms over the last SIX MONTHS when responding to each question.

Adulthood - Inattentive Symptoms

Adult A2. Do you often have difficulty sustaining your 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 A2a- Please provide details below if you have examples of the above suggestions, or if you have other examples not listed above:

Adult A4. Do you often not follow through on instructions and often fail to finish chores or duties in the workplace or your 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 you often avoid (or do you dislike, or are you 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 you 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 you 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 - Hyperactivity / Impulsivity Symptoms

The following questions assess your symptoms in adulthood. Please consider your symptoms over the last SIX MONTHS when responding to each question.

Adult H1. Do you often fidget with or tap hands or feet, or do you often squirm in your 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 you often leave your seat in situations where it is expected that you 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 you often feel restless?

Feeling restless or agitated insideConstantly having the feeling that you 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 you 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 you often “on the go” or do you 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 you restless or difficult to keep up withStepping over 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 you 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 you often blurt out an answer before questions have been completed?

Being a blabbermouth, saying what you 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 you often find it difficult to await your 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 you 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.

Adult Self-Report Scale (ASRS)

Section A

For each question below, please select the answer that most accurately reflects your feelings and behaviours for the past SIX MONTHS:

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *

Section B

For each question below, please select the answer that most accurately reflects your feelings and behaviours for the past SIX MONTHS:

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? *

When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish it themselves? *

Weiss Functional Impairment Rating Scale

This tool assists in understanding the impact your symptoms have on you and those around you. Please consider your symptoms for the past ONE MONTH. If you do not understand any of these questions or they are not relevant to you, select 'not applicable'

Family

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month

Problems balancing your needs against those of your family *

Work

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

School and Study

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

Life skills

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

Excessive or inappropriate use of internet or video games or TV *

Self Concept

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

Social

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

Risk

Please choose the option that best describes how your emotional or behavioural problems have affected each item in the last month:

Past Medical and Family History

This section will ask questions regarding your health, any symptoms you might be experiencing and your family history. This is done to ensure medications are prescribed safely if your diagnosis is confirmed.

Your Medical History

Please provide details if you have ticked any of the boxes:

Physical symptoms

Please provide details if you have ticked any of the boxes

Drug and Alcohol History

How much alcohol do you drink per day/week?

Please list any recreational drugs you have use in the last 5 years. Please list how often you use them.

Specialists

Have you seen any of the following specialists in the past? *

CardiologistNeurologist Respiratory specialistNone of the above

If you have ticked one of the boxes above, please provide details regarding your specialist review:

Family History

The questions below relates to your family history of medical conditions. This is to assist your psychiatrist in assessing your genetic risk for health conditions that are relevant to ADHD prescribing. As such, please only respond regarding your blood relatives. Consider close relatives such as parents, siblings, aunts, uncles, grandparents, cousins and your own children (if applicable).

Please answer to the best of your ability. If you are unsure about the answers, please discuss this with your family before your appointment with your psychiatrist. If you do not know your family history and you are unable to confirm your family history, please tick the box below.

Please indicate if any family members have the following conditions:

Heart diseaseHigh blood pressureHeart attackStrokeTransient ischaemic attack (TIA or mini stroke)Arrhythmia (abnormality in the electrical conduction in the heart)Sudden unexplained death under the age of 40I am not aware of my family history and I am unable to confirm my family history

If you would like to provide further details about your family history, please enter this below:

Medical History Declaration

I declare that the medical and family history information I have provided is correct. I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me and may place me at risk of adverse medical outcomes. * *

Important Information

Please read the following information regarding appointments and prescribing rules. You will be required to acknowledge you have read this information before any medication will be prescribed, so it is important to read it carefully.

Appointment information

Appointment Schedule

If the ADHD diagnosis is confirmed, and you are prescribed a stimulant medication after medical screening, you will need to attend a number of appointments for dose adjustments. Dose adjustment appointments are usually 15 minutes in duration. The total number of appointments required will depend on your response to the medication. Many people respond to the first medication prescribed, and only require 2-3 dose adjustment appointments.

In some cases, the first medication prescribed is not as effective as hoped, and other medications need to be trialled. Unfortunately, there is no way to predict which medication would be most suitable for each individual. We therefore start with the medication most people respond to, before moving on to other medications if required. If you require a switch to another medication, you will likely require 5 or more appointments in total.

Once you have settled on an effective medication, you will then need to attend 6 monthly for repeat prescriptions. In some cases, we can do 12 monthly appointments if your GP is willing to co-prescribe medications. This will be discussed in further detail with you at your appointments. WA Health Department guidelines require a psychiatrist to review a person on stimulants at least every 12 months in order to continue prescribing.

Prescribing information

Important Information Regarding Stimulant Prescribing

If you are prescribed a stimulant medication, it is important to note the following rules and expectations:

- Stimulants are highly regulated schedule 8 drugs. The health department specifies strict prescribing rules and your psychiatrist must comply with these rules.

- Your prescriptions are required by the health department to have a nominated script interval. This is the minimum number of days before you can collect the next script. The interval is written on the script and you can confirm your interval with your psychiatrist or pharmacist

- Requests for authorisation to collect scripts early will not be provided. If you lose medication or it is stolen, you will need to wait until the next collection date. It is important to protect your medication to avoid running out early.

- Do not take extra medication beyond the prescribed dose. Doing so will result in your prescription being cancelled.

- Do not share your medication with someone else. Doing so will result in your prescription being cancelled.

- You will be required to undertake regular urine drug screening to continue being prescribed your stimulant medication. Failure to complete the urine drug screening will result in your treatment being ceased. This is a health department requirement.

- Stimulant scripts will not be provided outside of appointments. It is important to make sure your appointment is scheduled before you run out of medication. If you do not do so, you will need to go without medication until your appointment.

I declare that I have read and understood the above information regarding the rules and expectations with stimulant prescribing. * *

Schedule 8 Prescriber Code

The WA Health Department Schedule 8 Medicines Prescribing Code requires psychiatrists to confirm a patient does not have any of the following conditions:

- A history of stimulant induced psychosis

- A history of bipolar disorder

- A history of subsatnce abuse , diversion or misuse of drugs of addiction or Schedule 9 poisons within the last five years

- A record of drug dependence or oversupply

- Be a current CPOP participant

The code expects prescribers to make reasonable steps to exclude the above conditions. This involves calling the Department of Health Schedule 8 Prescriber Information Service to obtain your schedule 8 and stimulant prescribing history. You will be asked below to confirm you consent to this service being called prior to any stimulants being prescribed. If you choose not to consent, you will not be prescribed a stimulant.

Do you consent to your psychiatrist calling the Department of Health Schedule 8 Prescriber Information Service to obtain your schedule 8 prescribing history? *

YesNo

Do you meet any of the criteria mentioned above from the Schedule 8 Medicines Prescribing Code that would indicate a stimulant cannot be prescribed? *

YesNoI am not sure

Please check the box below to indicate you understand the statement below regarding your prescription:

I acknowledge my prescription will be cancelled if I have not been truthful in my answer above. * *

Submit Form

I consent to completing this ADHD screening form. If you agree with this statement, please select 'I agree': *

I agreeI do not agree

I declare that the above information is correct. I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me *

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