Texas Barkley Other Report: Current Symptoms Name of person to be rated * First Name Last Name Your name * First Name Last Name Your relationship to person being rated * Choose One - Mother Father Brother Sister Spouse Partner Friend Aunt Uncle Grandmother Grandfather Guardian Today's Date * MM DD 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 1 (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 * - Never or Rarely Sometimes Often Very Often Has difficulty sustaining his/her attention in tasks or fun activities * - Never or Rarely Sometimes Often Very Often Doesn't listen when spoken to directly * - Never or Rarely Sometimes Often Very Often Doesn't follow through on instructions and fails to finish work or chores * - Never or Rarely Sometimes Often Very Often Has difficulty organizing tasks and activities * - Never or Rarely Sometimes Often Very Often Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort * - Never or Rarely Sometimes Often Very Often Loses things necessary for tasks or activities * - Never or Rarely Sometimes Often Very Often Is easily distracted by extraneous stimuli or irrelevant thoughts * - Never or Rarely Sometimes Often Very Often Is forgetful in daily activities * - Never or Rarely Sometimes Often Very Often Section 2 (Hyperactivity) Choose one of the options in the menu. Fidget with hands or feet or squirm in seat * - Never or Rarely Somtimes Often Very Often Leaves his/her seat in classrooms or in other situations in which remaining seated is expected * - Never or Rarely Sometimes Often Very Often Shifts around excessively or feels restless or hemmed in * - Never or Rarely Sometimes Often Very Often Has difficulty engaging in leisure activities quietly (feels uncomfortable, or is loud or noisy) * - Never and 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) * - Never or Rarely Sometimes Often Very Often Section 3 (Impulsivity) Choose one of the options in the menu. Talk excessively (in social situations) * - Never or Rarely Sometimes Often Very Often Blurts out answers before questions have been completed, completes others' sentences, or jumps the gun * - Never or Rarely Sometimes Often Very Often Has difficulty awaiting his/her turn * - 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) * - Never or Rarely Sometimes Often Very Often Section 4 (Sluggish Cognitive Tempo) Choose one of the options in the menu. Is prone to daydreaming when he/she should be concentrating on something or working * - Never or Rarely Sometimes Often Very Often Has trouble staying alert or awake in boring situations * - Never or Rarely Sometimes Often Very Often Is easily confused * - Never or Rarely Sometimes Often Very Often Is easily bored * - Never or Rarely Sometimes Often Very Often Is spacey or "in a fog" * - Never or Rarely Sometimes Often Very Often Is lethargic, more tired than others * - Never or Rarely Sometimes Often Very Often Is underactive or has less energy than others * - Never or Rarely Sometimes Often Very Often Is slow moving * - Never or Rarely Sometimes Often Very Often Doesn't seem to process information as quickly or as accurately as others * - Never or Rarely Sometimes Often Very Often Section 5 For any of the above questions, did you answer "Often" or "Very often"? * - Yes No If so, how old was this person when those symptoms began? - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 If so, in which of these settings did those symptoms impair the person's functioning? Select all that apply School Home Work Social Relationships Thank you! Back to Patient Forms
