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Barkley Other Report: Childhood Symptoms
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Where are you located?
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Choose
Louisiana
Oklahoma
Texas
FIRST and LAST name of patient being evaluated
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Your answer
FIRST and LAST name of person filling out this form
*
Your answer
Your relationship to person being rated
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Your answer
Date
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MM
/
DD
/
YYYY
Instructions
You are being asked to describe the childhood behavior of someone whom you know well. How often did that person experience each of these problems? Please select the answer that best describes their behavior when they were a child
BETWEEN 5 AND 12 YEARS OF AGE.
Section One:
Inattention
Choose one of the options in the menu.
Failed to give close attention to details or made careless mistakes in his/her work or other activities
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Had difficulty sustaining his/her attention in tasks or fun activities.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Didn't listen when spoken to directly
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Avoided, disliked, or was reluctant to engage in tasks that required sustained mental effort
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Lost things necessary for tasks or activities
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Was easily distracted by extraneous stimuli or irrelevant thoughts
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Was forgetful in daily activities.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Didn't follow through on instructions and fail to finish work or chores.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Had difficulty organizing tasks and activities.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Two:
Hyperactivity
Choose one of the options listed in the dropdown for each question.
Fidgeted with hands or feet or squirmed in his/her seat
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Left his/her seat in classrooms or in other situations in which remaining seated was expected
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Shifted around excessively or felt restless or hemmed in
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Had difficulty engaging in leisure activities quietly (felt uncomfortable, or was loud or noisy)
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Was "on the go" or acted as if "driven by a motor"
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Talked excessively
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Blurted out answers before questions had been completed, completed others' sentences, or jumped the gun
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Had difficulty awaiting my turn
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Interrupted or intruded on others (butted into conversations or activities without permission or took over what others were doing)
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Three
Age of Onset
For any of the above questions, if you answered "Often" or "Very often",
how old were you when those symptoms began?
(if you didn't answer "Often" or "Very Often", please reply "Not Applicable"
*
Your answer
If so, in which of these settings did those symptoms impair your functioning?
Select all that apply.
School
Home
Social Relationships
Did not answer "Often" or "Very Often"
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