Texas Barkley Other Report: Childhood Symptoms Name of person to be rated * First Name Last Name Your name * First Name Last Name Your relationship to person being rated * - Mother Father Sister Brother Spouse Partner Friend Aunt Uncle Grandmother Grandfather Guardian Date 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 1 (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 * - Never or Rarely Sometimes Often Very Often Had difficulty sustaining his/her attention in tasks or fun activities * - Never or Rarely Sometimes Often Very Often Didn't listen when spoken to directly * - Never or Rarely Sometimes Often Very Often Didn't follow through on instructions and failed to finish work or chores * - Never or Rarely Sometimes Often Very Often Had difficulty organizing tasks and activities * - Never or Rarely Sometimes Often Very Often Avoided, disliked, or was reluctant to engage in tasks that required sustained mental effort * - Never or Rarely Sometimes Often Very Often Lost things necessary for tasks or activities * - Never or Rarely Sometimes Often Very Often Was easily distracted by extraneous stimuli or irrelevant thoughts * - Never or Rarely Sometimes Often Very Often Was forgetful in daily activities * - Never or Rarely Sometimes Often Very Often Section 2 (Hyperactivity - Implusivity) Choose one of the options in the menu. Fidgeted with his/her hands or feet or squirmed in his/her seat * - Never or Rarely Sometimes Often Very Often Left his/her seat in classrooms or in other situations in which remaining seated was expected * - Never and Rarely Sometimes Often Very Often Shifted around excessively or felt restless or hemmed in * - Never or Rarely Sometimes Often Very Often Had difficulty engaging in leisure activities quietly (felt uncomfortable, or was loud or noisy) * - Never or Rarely Sometimes Often Very Often Was "on the go" or acted as if "driven by a motor" * - Never or Rarely Sometimes Often Very Often Talked excessively * - Never or Rarely Sometimes Often Very Often Blurted out answers before questions had been completed, completed others' sentences, or jumped the gun * - Never or Rarely Sometimes Often Very Often Had difficulty awaiting his/her turn * - 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) * - Never or Rarely Sometimes Often Very Often Section 3 For any of the above questions, did you answer "Often" or "Very often"? * - Yes No If so, in which of these settings did those symptoms impair your functioning? Select all that apply School Home Social Relationships Thank you! Back to Patient Forms
