Texas Barkley Self Report: Childhood Symptoms Name * First Name Last Name Gender * - Male Female Age * - 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 Instructions For each question, please select the option that best describes your behavior WHEN YOU WERE A CHILD BETWEEN 5 AND 12 YEARS OF AGE. Section 1 (Inattention) Failed to give close attention to details or made careless mistakes in my work or other activities * - Never or Rarely Sometimes Often Very Often Had difficulty sustaining my 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 Fidgeted with hands or feet or squirmed in my seat * - Never or Rarely Sometimes Often Very Often Section 2 (Hyperactivity - Implusivity) Choose one of the options in the menu. Left my 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 my 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 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
