Portal Form

CogniBox Portal — Welcome

You have been invited to complete a structured clinical assessment questionnaire as part of your upcoming appointment.

This form collects information about your attention, concentration, mood, sleep, health history, and daily functioning. Your responses help your clinician understand your experiences before your consultation so that your appointment can focus on interpretation, discussion, and planning rather than basic data collection.

What to expect

• The assessment takes approximately 25–35 minutes to complete.

• You can save and return later if needed.

• Please answer honestly based on your usual experiences.

• There are no right or wrong answers.

Some questions relate to sensitive topics such as mood, anxiety, or safety. These questions are included because they help ensure that your clinician provides the safest and most appropriate care. If certain responses suggest that follow-up may be helpful, additional questions may appear automatically.

Important information

• Completing this questionnaire does not provide a diagnosis.

• A diagnosis can only be made after your clinician reviews your responses and meets with you.

• Completion of this form does not guarantee a diagnosis or specific treatment.

Your information is securely stored and will only be reviewed by your treating clinician as part of your assessment.

If you feel distressed while completing this form

You may pause at any time. If you are in immediate distress or feel unsafe, please contact your GP, a crisis support service, or emergency services (000 in Australia).

Before you begin, please confirm

I understand this assessment supports my clinical evaluation but does not itself provide a diagnosis. *

I understand my clinician will review my responses before my appointment. *

I consent to completing this assessment. *

CogniBox Portal Form

Patient Details

Please provide your details so your clinician can safely conduct your assessment and contact you if needed. All information is securely stored and handled in accordance with privacy legislation.

Full Legal Name *

Preferred Name *

Date of Birth *

Sex Assigned at Birth *MaleFemaleIntersexPrefer not to say

Gender IdentityMaleFemaleNon-binaryPrefer not to sayOther

Provide details

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Mobile Phone *

Email Address *

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Medicare Number

Individual Reference Number

Expiry Date

---

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

---

General Practitioner(if different from assessing doctor)

GP Contact(Phone or email)

GP Clinic

---

Do you consent to all of the entered details being sent to your GP? *

YesNo

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Primary Language Spoken *

Do you require an interpreter? *

YesNo

Language

---

Occupation / Study Status *

EmployedStudentBothNeither

Occupation

Course

---

HeightOptional but reccomended

WeightOptional, but reccommended

Is it safe to leave a voicemail or message on your phone *

YesNo

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Consent Statements

I confirm the information provided is accurate to the best of my knowledge. *

I consent to being contacted regarding my care. *

I understand that this assessment is part of a clinical evaluation process and does not itself provide a diagnosis. *

Age

IsMinor?

MedicareBlank?

InterpreterNeeded?

CogniBox Portal Form

CogniBox – ADHD Assessment Intake

This structured assessment collects information about attention, organisation, mood, sleep, and health history to support your clinician in conducting a comprehensive evaluation. There are no right or wrong answers. Please respond honestly based on your usual experiences.

This questionnaire does not provide a diagnosis. Diagnosis and treatment decisions are made only after clinical assessment by your doctor.

COGNIBOX MEDICAL DISCLAIMER

Important Notice – Please Read Carefully

1. Nature of the CogniBox Platform

CogniBox is a structured digital assessment support system designed to assist healthcare practitioners by collecting and organising patient-reported questionnaire information prior to clinical consultation.

CogniBox is not a medical service provider and does not offer medical care, clinical diagnosis, treatment, therapeutic intervention, or prescribing services. The platform functions solely as an information-gathering and reporting tool.

2. No Medical Advice

Information presented within CogniBox, including questionnaire items, automated scores, summaries, flags, or generated reports:

does not constitute medical advice

is not intended to diagnose any condition

must not be relied upon as a substitute for professional clinical judgement

should not be used to make health decisions independently

All health-related decisions must be made in consultation with a qualified healthcare professional.

3. Screening Tools Only

All questionnaires used within CogniBox are screening instruments. Screening tools:

identify patterns or symptom indicators

do not establish diagnoses

do not confirm or exclude medical conditions

may produce false positives or false negatives

Final interpretation must always be performed by a licensed clinician who considers clinical history, examination findings, collateral information, and professional judgement.

4. Self-Reported Information

CogniBox relies entirely on information entered by users. The platform:

cannot verify accuracy of responses

cannot confirm identity of respondent

cannot assess context or nuance

cannot detect intentional or unintentional misreporting

Results may be affected by incomplete, inaccurate, or misunderstood responses.

5. Clinical Responsibility

Use of CogniBox does not transfer or share clinical responsibility. The treating clinician retains sole responsibility for:

diagnosis

prescribing decisions

treatment planning

risk assessment

follow-up care

CogniBox does not assume responsibility for clinical outcomes or decisions made by healthcare practitioners.

6. No Therapeutic Relationship

Use of the CogniBox platform does not create:

a doctor–patient relationship

a therapeutic relationship

a duty of care

Any therapeutic relationship exists only between the patient and their treating clinician.

7. Risk and Safety Limitation

CogniBox is not an emergency or monitoring service.

The platform:

does not monitor responses in real time

does not provide alerts to emergency services

does not provide crisis intervention

cannot respond to urgent mental health risk

If you are experiencing distress, thoughts of self-harm, or a medical emergency, you must immediately contact emergency services or an appropriate crisis support provider.

8. Platform Limitations

You acknowledge that:

automated scoring is algorithm-based

summaries are computer-generated

technical errors may occur

system interruptions may occur

CogniBox does not guarantee uninterrupted operation or error-free performance.

9. Appropriate Use

CogniBox is intended solely for use:

as a structured assessment support tool

under referral from a clinician

as part of a broader clinical evaluation

It must not be used:

for self-diagnosis

for independent clinical decision-making

as a replacement for medical care

10. Acceptance of Disclaimer

If you do not agree with this disclaimer, you must not use the platform.

Version: CogniBox Medical Disclaimer v1.2
Last updated: 02/02/2026

I accept these terms *

CogniBox Portal Form

Presenting Concerns

What prompted you to seek assessment? *

What difficulties are you currently experiencing? *

Which area is most affected? *

WorkStudyOrganisationRelationshipsEmotional regulationDaily functioningOther

CogniBox Portal Form

Attention & Concentration Symptoms

How often do these apply to you?

I make careless mistakes in tasks *

NeverRarelySometimesOftenVery Often

I struggle to sustain attention *

NeverRarelySometimesOftenVery Often

I seem not to listen when spoken to *

NeverRarelySometimesOftenVery Often

I fail to complete tasks *

NeverRarelySometimesOftenVery Often

I struggle to organise activities *

NeverRarelySometimesOftenVery Often

I avoid tasks requiring mental effort *

NeverRarelySometimesOftenVery Often

I frequently lose important items *

NeverRarelySometimesOftenVery Often

I am easily distracted *

NeverRarelySometimesOftenVery Often

I forget daily responsibilities *

NeverRarelySometimesOftenVery Often

Inattention_Total

CogniBox Portal Form

Hyperactivity & Impulsivity

How often do these apply to you?

I feel restless or fidgety *

NeverRarelySometimesOftenVery Often

I struggle to remain seated *

NeverRarelySometimesOftenVery Often

I feel internally driven or “on the go” *

NeverRarelySometimesOftenVery Often

I find it hard to relax quietly *

NeverRarelySometimesOftenVery Often

I talk excessively *

NeverRarelySometimesOftenVery Often

I blurt out answers *

NeverRarelySometimesOftenVery Often

I struggle to wait my turn *

NeverRarelySometimesOftenVery Often

I interrupt others *

NeverRarelySometimesOftenVery Often

I act impulsively *

NeverRarelySometimesOftenVery Often

Hyperactive_Total

CogniBox Portal Form

Functional Impact

Which areas are affected?

WorkStudyRelationshipsHousehold managementTime managementFinancesDrivingEmotional controlOrganisation

Work

NoneMildModerateSignificantSevere

Study

NoneMildModerateSignificantSevere

Relationships

NoneMildModerateSignificantSevere

Household management

NoneMildModerateSignificantSevere

Time management

NoneMildModerateSignificantSevere

Finances

NoneMildModerateSignificantSevere

Driving

NoneMildModerateSignificantSevere

Emotional control

NoneMildModerateSignificantSevere

Organisation

NoneMildModerateSignificantSevere

Impairment_Level

CogniBox Portal Form

Childhood History (Before Age 12)

Easily distracted at school *

YesNoUnsure

Lost belongings frequently *

YesNoUnsure

Difficulty finishing schoolwork *

YesNoUnsure

Teachers reported attention concerns *

YesNoUnsure

Restless or fidgety *

YesNoUnsure

Talked excessively *

YesNoUnsure

Acted without thinking *

YesNoUnsure

Difficulty waiting turns *

YesNoUnsure

Academic underperformance *

YesNoUnsure

Did teachers or parents raise concerns about attention or behaviour? *

YesNoUnsure

Childhood History Total

CogniBox Portal Form

Symptom Course

At what age did symptoms begin?

Have symptoms been present most of your life?

YesNo

Did symptoms worsen in adolescence?

YesNo

Have symptoms changed in adulthood?

YesNo

CogniBox Portal Form

Mood Screening

Over the last 2 weeks how often have you experienced

Low mood *

Not at allSeveral dayMore than half the daysNearly every day

Loss of interest *

Not at allSeveral dayMore than half the daysNearly every day

Low energy *

Not at allSeveral dayMore than half the daysNearly every day

Poor concentration *

Not at allSeveral dayMore than half the daysNearly every day

Sleep problems *

Not at allSeveral dayMore than half the daysNearly every day

Appetite change *

Not at allSeveral dayMore than half the daysNearly every day

Feeling worthless *

Not at allSeveral dayMore than half the daysNearly every day

Moving slowly or restlessly *

Not at allSeveral dayMore than half the daysNearly every day

Thoughts you would be better off dead or hurting yourself *

Not at allSeveral dayMore than half the daysNearly every day

Mood_Total

Are you currently safe?

YesNoUnsure

Anything you want your clinician to know?

CogniBox Portal Form

Anxiety Screening

Excessive worry *

Not at allSeveral dayMore than half the daysNearly every day

Difficulty controlling worry *

Not at allSeveral dayMore than half the daysNearly every day

Restlessness *

Not at allSeveral dayMore than half the daysNearly every day

Muscle tension *

Not at allSeveral dayMore than half the daysNearly every day

Irritability *

Not at allSeveral dayMore than half the daysNearly every day

Trouble concentrating due to worry *

Not at allSeveral dayMore than half the daysNearly every day

Anxiety_Total

CogniBox Portal Form

Elevated Mood Screening

Periods of unusually high energy

YesNo

Needing less sleep

YesNo

Feeling unusually confident or elevated

YesNo

Racing thoughts

YesNo

Taking risks or acting impulsively

YesNo

Others noticed you acting differently

YesNo

PAGE 10 Hidden

Your responses suggest experiences your clinician may explore further.

CogniBox Portal Form

Sleep

Average hours of sleep per night

Do you wake refreshed?

YesNo

Difficulty falling asleep?

YesNo

Wake frequently?

YesNo

Loud snoring?

YesNo

Has anyone noticed breathing pauses?

YesNo

CogniBox Portal Form

Alcohol Use

How often do you drink alcohol? *

NeverMonthly or less2–4 times a month2–3 times a week4+ times a week

Typical drinks per day *

1-23-45-67-910+

6+ drinks on one occasion *

NeverLess than monthlyMonthlyWeeklyDaily

Alcohol_Total

CogniBox Portal Form

Substance Use

Have you used non-prescribed substances in past 12 months?

YesNo

Substances used

CannabisStimulantsMDMAOpioidsBenzodiazepinesOther

Provide details

Frequency

Once or twiceMonthlyWeeklyDaily

Have they caused problems?

YesNo

Provide details

CogniBox Portal Form

Medical Safety

Heart disease *

YesNo

Palpitations *

YesNo

Fainting episodes *

YesNo

Chest pain on exertion *

YesNo

Family sudden cardiac death <40 *

YesNo

Known arrhythmia *

YesNo

Congenital heart condition *

YesNo

Please describe any other background medical condition and treatment

CogniBox Portal Form

Medication & Risk History

Previous stimulant medication

YesNo

Previous refusal of stimulants

YesNo

Past substance dependence

YesNo

Misuse of prescription medication

YesNo

Legal issues related to substances

YesNo

Medication Risk History TOTAL

CogniBox Portal Form

Final Questions

What is your biggest current difficulty?

What would you most like help with?

Any additional relevant information?

I confirm the information provided is accurate to the best of my knowledge *

CogniBox Portal Form

Submission Complete

Thank you for completing your assessment. Your responses have been securely submitted and will be reviewed before your appointment.

If you feel unsafe or distressed before your appointment, please contact your GP, local crisis service, or emergency services immediately.

A second questionnaire, linked to Q-Global (Pearson Assessments) will be sent to you shortly. It is sent to this partner due to proprietary rights. 

There will be no additional cost to you.

COGNIBOX SCORING & LOGIC MATRIX

COGNIBOX SCORING & LOGIC MATRIX

1. MASTER VARIABLE DEFINITIONS

Inattention_Total

Hyperactive_Total

Mood_Total

Anxiety_Total

Alcohol_Total

Impairment_Level

Derived variables:

ADHD_Total

2. ADHD SYMPTOM SCORING LOGIC

Inattention Domain Flag

InattentionFlag

Rationale: ≥50% average frequency suggests clinically significant symptom burden.

Hyperactive Domain Flag

HyperactiveFlag

Overall ADHD Symptom Flag

ADHD_SymptomFlag

3. IMPAIRMENT REQUIREMENT LOGIC

DSM requirement: symptoms must cause impairment.

ImpairmentFlag

4. CHILDHOOD ONSET SUPPORT FLAG

ChildhoodFlag

5. COURSE CONSISTENCY FLAG

CourseFlag

6. ADHD LIKELIHOOD INDICATOR (NON-DIAGNOSTIC)

This is NOT a diagnosis. It is a clinician prioritisation flag.

ADHD_Likelihood

7. MOOD RISK SCORING

DepressionFlag

SevereMoodFlag

8. ANXIETY SCORING

AnxietyFlag

SevereAnxietyFlag

9. BIPOLAR SCREEN LOGIC

BipolarScreenPositive

This does NOT diagnose bipolar. It only flags clinician review.

10. SLEEP RISK FLAGS

SleepApneaRisk

SevereSleepDeprivation

11. ALCOHOL RISK

AlcoholRiskFlag

HighAlcoholRiskFlag

12. SUBSTANCE RISK

SubstanceFlag

HighSubstanceFlag

13. CARDIAC SAFETY FLAG

CardiacFlag

14. MEDICATION RISK FLAG

MedicationRiskFlag

15. GLOBAL COMPLEXITY INDEX

ComplexityScore

16. MASTER CLINICAL PRIORITY FLAG

PriorityLevel

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