Child & Adolescent ADHD Assessment

Introduction

Why this assessment is required.

Attention difficulties can arise from many different causes — including anxiety, depression, sleep problems, substance use, medical conditions, or neurodevelopmental differences.

Before any diagnosis is made, it is important to:

understand your/your child’s current symptoms
explore how they affect daily functioning
consider other possible contributing factors
assess safety and medical history
document relevant developmental history

This structured pre-assessment ensures that your clinician has the necessary information to conduct a careful, evidence-based evaluation. Completing this questionnaire allows your appointment time to focus on interpretation, clarification, and planning - rather than basic data gathering. This process supports accurate diagnosis and safe treatment decisions.

Child & Adolescent ADHD Assessment

Consent

Please read this before starting the questionnaire.

Purpose
This form collects information to assist a clinician in assessing ADHD and related conditions.

Limits

This form does not provide a diagnosis.
This form does not replace clinical assessment.
This is not an emergency service.

Safety
If there is immediate risk of harm, call 000 or attend the nearest Emergency Department.

School Contact
The clinician may contact the school for relevant collateral information as part of assessment.

Privacy
Your information is treated as confidential health information and shared only for care, legal obligations, or serious safety concerns.

Confirmation

I confirm I am the parent/guardian or have legal authority to provide this informationI understand this is not a diagnosis and does not replace clinical assessment *

I understand this is not an emergency serviceI consent to sharing this information with the referring clinician and (if required) the school *

I am a parent/legal guardian *

I consent to providing information *

I understand not a diagnosis *

Not an emergency service *

Consent to school contact *

Full name

Phone

Electronic Signature

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Date

Child & Adolescent ADHD Assessment

Demographics

Child full name *

Date of birth *

Age

Year/Grade *

School name *

School contact email

Custody / decision-making arrangement *

Sole parental responsibilityShared custody / joint decision makingOther/unsure

Clinician may request confirmation of shared consent.

If available, provide details of shared decision-making

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Child & Adolescent ADHD Assessment

Presenting Concerns

What concerns led you to seek an assessment? *

Overall severity *

MildModerateSevere

Child & Adolescent ADHD Assessment

ADHD Symptoms (DSM-5 aligned)

Inattention

1. Careless mistakes / poor attention to detail

NeverSometimesOftenVery often

2. Difficulty sustaining attention

NeverSometimesOftenVery often

3. Seems not to listen

NeverSometimesOftenVery often

4. Does not follow through / complete tasks

NeverSometimesOftenVery often

5. Difficulty organising tasks

NeverSometimesOftenVery often

6. Avoids sustained mental effort tasks

NeverSometimesOftenVery often

7. Loses things

NeverSometimesOftenVery often

8. Easily distracted

NeverSometimesOftenVery often

9. Forgetful in daily activities

NeverSometimesOftenVery often

Hyperactivity / Impulsivity

1. Fidgets / squirms

NeverSometimesOftenVery often

2. Leaves seat when expected to remain seated

NeverSometimesOftenVery often

3. Runs/climbs inappropriately (or restless)

NeverSometimesOftenVery often

4. Unable to play quietly

NeverSometimesOftenVery often

5. “On the go” / as if driven by a motor

NeverSometimesOftenVery often

6. Talks excessively

NeverSometimesOftenVery often

7. Blurts out answers

NeverSometimesOftenVery often

8. Difficulty waiting turn

NeverSometimesOftenVery often

9. Interrupts / intrudes

NeverSometimesOftenVery often

Functional Impairment

Home

No impactSome impactSignificant impactOverwhelming

School

No impactSome impactSignificant impactOverwhelming

Peers/Friendships

No impactSome impactSignificant impactOverwhelming

Activities

No impactSome impactSignificant impactOverwhelming

Child & Adolescent ADHD Assessment

Behaviour & Risk

General Behaviour Pattern

YesNo

Are behaviour difficulties present in more than one setting (e.g., home and school)?

YesNo

Have concerns been present for at least 6 months?

YesNo

Do behaviours cause significant distress or impairment in family, school, or peer functioning?

YesNo

Oppositional Behaviour (tick any that apply)

Conduct-Type Behaviours (tick any that apply)

Physical aggression toward peopleBullying or threatening behaviourCruelty to animalsDeliberate destruction of propertyStealing without confrontationLying to obtain goods or avoid obligationsStaying out late without permission (age inappropriate)Running away from homeSchool refusal or truancy

Emotional & Behavioural Regulation (tick any that apply)

Severe temper outbursts (verbal or physical)Outbursts out of proportion to situationPersistent irritability between outburstsDifficulty calming once upsetSudden mood shifts

Impulse & Risk Behaviour (tick any that apply)

Acts without thinking of consequencesEngages in risky or dangerous activitiesDifficulty waiting turn.Intrudes on others' activities

Social Behaviour (tick any that apply)

Difficulty maintaining friendshipsRejected by peers due to behaviourDifficulty interpreting social cuesManipulative or controlling behaviour

Parent Perception

What situations trigger behavioural problems?

What strategies have helped?

What makes behaviour worse?

Child & Adolescent ADHD Assessment

School Functioning Details

Teacher feedback (selectall that apply, as far as you are aware)*please note that a questionnaire will be sent to your nominated contact at school

Academic performance compared to ability

Below expectedAt expectedAbove expectedUnsure

Does performance vary depending on interest level?

YesNoUnsure

Safety & Awareness (select all that apply)

Runs into unsafe situationsPoor awareness of dangerImpulsive risk-takingDifficulty following safety rulesNone

History of injuries related to impulsivity?

YesNo

Describe

Sensory & Motor Profile (select all that apply)

Parent Concern Priorities

Top 3 goals for assessment outcome

What would improvement look like in daily life?

Child & Adolescent ADHD Assessment

Family History

Some conditions can run in families and may be relevant to attention, behaviour, mood, or medication safety.
Please indicate if any close relatives (parents, siblings, grandparents) have had the following:

Neurodevelopmental / Learning

ADHD / attention difficultiesAutism spectrumdisorderLearning disorder (dyslexia, dyscalculia, etc.)Tics or Tourette syndrome

Neurological

Epilepsy / seizuresMigraines

Cardiac (Medication Safety)

Sudden unexplained death under age 40Inherited heart rhythm disorder / arrhythmia

Additional family history details (optional)

cardiac family risk flag

Child & Adolescent ADHD Assessment

Medical History (Child)

These questions help identify health factors that may affect attention, behaviour, learning, and medication safety.

General Health

Does your child have any diagnosed medical conditions?

YesNo

Please list diagnose

Neurological

Has your child ever had

Seizures / epilepsySignificant head injury / concussionFrequent headaches / migrainesTics / Tourette’s

Cardiac / Fainting

Has your child ever had

Known heart conditionFainting / unexplained collapseChest pain or palpitations with exerciseUnusual breathlessness with exertion

Hearing / Vision

Has your child had

Hearing problems or recurrent ear infectionsVision problems (needs glasses/concerns)

Allergies / Asthma / Eczema

AsthmaEczemaFood allergiesMedication allergies

Allergy details

Current Medications

Please list all current medications and supplements (include dose if known)

Previous Treatments / Supports

Has your child previously received any of the following?

Child & Adolescent ADHD Assessment

Sleep Assessment

Sleep problems can affect attention, mood, and behaviour. Please answer the following questions based on your child’s usual sleep over the past 3 months.

Sleep Schedule

Usual bedtime on school nightsUsual wake time on school morningsUsual bedtime on weekendsUsual wake time on weekends

Sleep Onset

How long does it usually take your child to fall asleep?

Less than 15 minutes15–30 minutes30–60 minutesMore than 60 minutes

Sleep Difficulties

How often does your child experience the following?

Difficulty falling asleep

NeverOccasionallyOftenAlmost every night

Waking during the night

NeverOccasionallyOftenAlmost every night

Difficulty waking in the morning

NeverOccasionallyOftenAlmost every day

Daytime Effects

How often does your child:

Seem very sleepy during the day?

NeverOccasionallyOftenAlmost every day

Fall asleep in the car, school, or quiet situations?

NeverOccasionallyOftenAlmost every day

Any other sleep concern

Child & Adolescent ADHD Assessment

Developmental History

Developmental Screening Across Childhood (Brief Parent Questionnaire). Please select the most appropriate response. If unsure, select Unsure.

Pregnancy & Birth

Any complications during pregnancy?

YesNoUnsureNot applicable

Prematurity (<37 weeks)?

YesNoUnsureNot applicable

Birth complications (NICU admission, oxygen, jaundice treatment)?

YesNoUnsureNot applicable

Low birth weight (<2.5kg)?

YesNoUnsureNot applicable

Known genetic or medical conditions?

YesNoUnsureNot applicable

Details

Infancy (0–2 years)

Sat without support by 9 months?

YesNoUnsureNot applicable

Walked independently by 18 months?

YesNoUnsureNot applicable

Ongoing clumsiness or poor coordination?

YesNoUnsureNot applicable

First words by 18 months?

YesNoUnsureNot applicable

Two-word phrases by 2 years?

YesNoUnsureNot applicable

Any speech delay or speech therapy?

YesNoUnsureNot applicable

Made eye contact as a baby?

YesNoUnsureNot applicable

Responded to name?

YesNoUnsureNot applicable

Showed interest in people?

YesNoUnsureNot applicable

Excessively irritable or difficult to settle?

YesNoUnsureNot applicable

Feeding difficulties?

YesNoUnsureNot applicable

Significant sleep disturbance?

YesNoUnsureNot applicable

Preschool Years (3–5 years)

Clear speech by age 4?

YesNoUnsureNot applicable

Difficulty understanding instructions?

YesNoUnsureNot applicable

Literal interpretation of language?

YesNoUnsureNot applicable

Engaged in imaginative play?

YesNoUnsureNot applicable

Played cooperatively with peers?

YesNoUnsureNot applicable

Difficulty sharing or turn-taking?

YesNoUnsureNot applicable

Frequent severe tantrums?

YesNoUnsureNot applicable

Aggression beyond expected for age?

YesNoUnsureNot applicable

Very high activity level?

YesNoUnsureNot applicable

Difficulty sitting during group time?

YesNoUnsureNot applicable

Unusual sensitivity to noise, clothing, textures?

YesNoUnsureNot applicable

Strong aversions to certain foods?

YesNoUnsureNot applicable

Regression

Any loss of previously acquired skills (speech, toileting, social skills)?

YesNoUnsureNot applicable

Child & Adolescent ADHD Assessment

Strengths and Difficulties Questionnaire (SDQ)

For each item, please tick one box that best describes your child’s behaviourover the past six months or school year.

1. Considerate of other people's feelings

Not trueSomewhat trueCertainly true

2. Restless, overactive, cannot stay still for long

Not trueSomewhat trueCertainly true

3. Often complains of headaches, stomach-aches or sickness

Not trueSomewhat trueCertainly true

4. Shares readily with other children

Not trueSomewhat trueCertainly true

5. Often loses temper

Not trueSomewhat trueCertainly true

6. Would rather be alone than with other children

Not trueSomewhat trueCertainly true

7. Generally well behaved, usually does what adults request

Not trueSomewhat trueCertainly true

8. Many worries or often seems worried

Not trueSomewhat trueCertainly true

9. Helpful if someone is hurt, upset or feeling ill

Not trueSomewhat trueCertainly true

10. Constantly fidgeting or squirming

Not trueSomewhat trueCertainly true

11. Has at least one good friend

Not trueSomewhat trueCertainly true

12. Often fights with other children or bullies them

Not trueSomewhat trueCertainly true

13. Often unhappy, depressed or tearful

Not trueSomewhat trueCertainly true

14. Generally liked by other children

Not trueSomewhat trueCertainly true

15. Easily distracted, concentration wanders

Not trueSomewhat trueCertainly true

16. Nervous in new

Not trueSomewhat trueCertainly true

17. Kind to younger children

Not trueSomewhat trueCertainly true

18. Often lies or cheats

Not trueSomewhat trueCertainly true

19. Picked on or bullied by other children

Not trueSomewhat trueCertainly true

20. Often volunteers to help others

Not trueSomewhat trueCertainly true

21. Thinks things out before acting

Not trueSomewhat trueCertainly true

22. Steals from home,

Not trueSomewhat trueCertainly true

23. Gets along better with adults than with other children

Not trueSomewhat trueCertainly true

24. Many fears, easily scared

Not trueSomewhat trueCertainly true

25. Good attention span, sees tasks through to the end

Not trueSomewhat trueCertainly true

Additional comments

SDQ Emotional

SDQ Conduct

SDQ Hyperactivity

SDQ Peer

SDQ Prosocial

SDQ Total Difficulties

Child & Adolescent ADHD Assessment

NICHQ Vanderbilt Assessment Scale - Parent Informant

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.

Is this evaluation based on a time when the child

was on medicationwas not on medicationnot sure

Symptoms

1. Does not pay attention to details or makes careless mistakes (e.g., homework)