Please select the option next to each item that best describes your behaviour when you were a child. PLEASE RATE YOUR BEHAVIOUR BETWEEN 7 and 12 YEARS OF AGE.
Failed to give close attention to details or made careless mistakes in my work
Fidgeted with hands or feet or squirmed in seat
Had difficulty sustaining my attention in tasks or fun activities
Left my seat in classroom or other situations in which sitting was expected
Didn’t listen when spoken to directly
Problems taking care of your family
Didn’t follow through on instructions and failed to finish work
Had difficulty engaging in leisure activities or doing fun things quietly
Had difficulty organising tasks and activities
Felt “on the go” or acted as if “driven by a motor”
Avoided, disliked, or was reluctant to engage in work that required sustained mental effort
Talked excessively
Lost things necessary for tasks or activities
Blurted out answers before questions had been completed
Easily distracted
Had difficulty awaiting turn
Forgetful in daily activities
Interrupted or intruded on others
To what extent did the problems you may have circled on the previous page interfere with your ability to function in each of these areas of life activities when you were a child between 7 and 12 years of age?
In your home life with your immediate family
In your social interactions with other children
In your activities or dealings in the community
In school
In sports, clubs, or other organisations
In learning to take care of yourself
In your play, leisure or recreational activities
In your handling of your daily chores or other responsibilities
