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Barkley Other Report: Current Symptoms
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Where are you located?
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Choose
Louisiana
Oklahoma
Texas
First and Last name of Person to be Rated
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Your answer
Your First and Last Name
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Your answer
Your relationship to person being rated
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Your answer
Today's Date
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MM
/
DD
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YYYY
Instructions
You are being asked to describe the behavior of someone whom you know well. How often does that person experience each of these problems? Please select the answer that best describes the person's behavior
DURING THE PAST 6 MONTHS.
Section One:
Inattention
Choose one of the options in the menu.
Fails to give close attention to details or makes careless mistakes in his/her work or other activities
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Has difficulty sustaining their attention in tasks or fun activities
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Doesn't listen when spoken to directly.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Doesn't follow through on instructions and fails to finish work or chores.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Has difficulty organizing tasks and activities
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Lose things necessary for tasks or activities.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is easily distracted by extraneous stimuli or irrelevant thoughts
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is forgetful in daily activities.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Two:
Hyperactivity
Choose one of the options on the menu
Fidget with hands or feet or squirm in seat.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Leaves their seat in classrooms or in other situations in which remaining seated is expected
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Shift around excessively or feel restless or hemmed in.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Has difficulty engaging in leisure activities quietly (feels uncomfortable, or is loud or noisy)
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is "on the go" or acts as if "driven by a motor" (or he/she feels like he/she has to be busy or always doing something)
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Three:
Impulsivity
Choose one of the options listed in the dropdown for each question.
Talk excessively (in social situations
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Blurts out answers before questions have been completed, complete others' sentences, or jump the gun.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Has difficulty awaiting their turn
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Interrupts or intrudes on others (butts into conversations or activities without permission or takes over what others are doing)
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Four:
Cognitive Tempo
Choose one of the options listed in the dropdown for each question.
Is prone to daydreaming when he/she should be concentrating on something or working
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Has trouble staying alert or awake in boring situations.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is easily confused.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is easily bored.
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is spacey or "in a fog"
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is lethargic, more tired than others
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is underactive or has less energy than others
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Is slow moving
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Doesn't seem to process information as quickly or as accurately as others
*
Choose
Never or Rarely
Sometimes
Often
Very Often
Section Five
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 the person's functioning?
Select all that apply.
*
School
Home
Work
Social Relationships
Did not answer "Often" or "Very Often"
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