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ADHD Diagnostic Questionnaire for Parents

Introduction

This questionnaire is designed to help parents assess whether their child may exhibit symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a neurodevelopmental condition characterized by persistent inattention, hyperactivity, and/or impulsivity that impacts daily functioning, such as school performance, social interactions, or home life. The questions below are based on standard diagnostic criteria and aim to gather detailed information about your child’s behavior.

Instructions:

• Answer each question based on your child’s behavior over the past 6 months.
• Rate the frequency of each behavior using the scale: Never (0), Rarely (1), Sometimes (2), Often (3), Very Often (4).
• Provide specific examples where possible to help clarify your responses.
• Complete the additional sections on impact, settings, and history to provide a full picture.
• Share the completed questionnaire with a healthcare professional (e.g., pediatrician, psychologist, or psychiatrist) for a formal evaluation. This questionnaire is not a substitute for a professional diagnosis.

Part 1: Inattention Symptoms

Rate how often your child displays the following behaviors:

1. Fails to give close attention to details or makes careless mistakes in schoolwork, chores, or other activities (e.g., overlooking details in math problems or instructions).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

2. Has difficulty sustaining attention in tasks or play activities (e.g., loses focus during reading, homework, or conversations).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

3. Does not seem to listen when spoken to directly (e.g., appears distracted even when there are no obvious distractions).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

4. Does not follow through on instructions and fails to finish schoolwork, chores, or tasks (not due to defiance or lack of understanding).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

5. Has difficulty organizing tasks and activities (e.g., messy workspace, poor time management, forgets deadlines or materials).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

6. Avoids or is reluctant to engage in tasks that require sustained mental effort (e.g., homework, studying, or puzzles).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

7. Loses things necessary for tasks or activities (e.g., school supplies, books, toys, or clothing).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

8. Is easily distracted by external stimuli (e.g., noises, unrelated thoughts, or objects).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

9. Is forgetful in daily activities (e.g., forgets to do chores, bring items to school, or relay messages).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

Part 2: Hyperactivity and Impulsivity Symptoms

Rate how often your child displays the following behaviors:

1. Fidgets with hands or feet or squirms in seat (e.g., tapping pencils, bouncing legs, or inability to sit still).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

2. Leaves seat in situations where remaining seated is expected (e.g., during class, meals, or meetings).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

3. Runs about or climbs in situations where it is inappropriate (e.g., in classrooms or stores; in adolescents, this may be feeling restless).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

4. Is unable to play or engage in leisure activities quietly (e.g., always loud or disruptive during play).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

5. Is “on the go” or acts as if “driven by a motor” (e.g., constantly moving, unable to relax).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

6. Talks excessively (e.g., speaks out of turn or dominates conversations).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

7. Blurts out answers before questions are completed (e.g., interrupts or finishes others’ sentences).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

8. Has difficulty waiting for their turn (e.g., in lines, games, or conversations).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

9. Interrupts or intrudes on others (e.g., butts into conversations, games, or activities).

   • Rating: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4
   • Example: ________________________________________________________

Part 3: Impact of Symptoms

To understand how these behaviors affect your child’s life, answer the following:

1. Does your child’s behavior significantly impair their academic performance?

   • Yes [ ] No
   • If yes, describe (e.g., low grades, incomplete assignments): ______________________________

2. Does your child’s behavior affect their relationships with peers or family members?

   • Yes [ ] No
   • If yes, describe (e.g., conflicts, peer rejection): ____________________________________

3. Does your child’s behavior interfere with their ability to follow rules or routines at home or school?

   • Yes [ ] No
   • If yes, describe (e.g., frequent discipline, inability to complete chores): __________________

4. Have teachers, caregivers, or others expressed concerns about your child’s attention or behavior?

   • Yes [ ] No
   • If yes, provide details: ________________________________________________________

Part 4: Settings and Consistency

1. In which settings do these behaviors occur? (Check all that apply)

   • Home
   • School
   • Public places (e.g., stores, parks)
   • Social gatherings
   • Other: ________________________

2. Are these behaviors consistent across different settings, or do they vary?

   • Consistent (similar in most settings)
   • Vary (more pronounced in specific settings)
   • If they vary, describe: ________________________________________________________

3. Do these behaviors occur with different people (e.g., parents, teachers, peers)?

   • Yes, with most people
   • No, only with specific people
   • If no, specify: ______________________________________________________________

Part 5: Developmental and Medical History

1. At what age did you first notice these behaviors?

   • Age: ________
   • Describe initial concerns: ____________________________________________________

2. Were there any complications during pregnancy, birth, or early development? (e.g., premature birth, low birth weight, developmental delays)

   • Yes [ ] No
   • If yes, describe: ________________________________________________________

3. Does your child have any diagnosed medical or psychological conditions? (e.g., anxiety, learning disabilities, epilepsy)

   • Yes [ ] No
   • If yes, list: _____________________________________________________________

4. Is there a family history of ADHD or related conditions? (e.g., ADHD, anxiety, depression)

   • Yes [ ] No
   • If yes, describe: ________________________________________________________

5. Does your child take any medications or supplements?

   • Yes [ ] No
   • If yes, list: _____________________________________________________________

6. Has your child experienced significant stress or trauma? (e.g., family changes, bullying)

   • Yes [ ] No
   • If yes, describe: ________________________________________________________

Part 6: Additional Observations

1. What are your child’s strengths? (e.g., creativity, energy, empathy)

   • ---

2. What strategies have you tried to manage your child’s behavior? (e.g., routines, rewards, discipline)

   • ---

   • How effective were they? _______________________________________________

3. Any other concerns or observations about your child’s behavior or development?

   • ---

Scoring and Next Steps

Scoring Guidance (for informational purposes; a professional will interpret results):

• Count the number of symptoms rated Often (3) or Very Often (4) in each section.
• Inattention: 6 or more symptoms may indicate the Inattentive presentation of ADHD.
• Hyperactivity/Impulsivity: 6 or more symptoms may indicate the Hyperactive-Impulsive presentation.
• Combined Presentation: 6 or more symptoms in both categories may suggest Combined ADHD.
• Symptoms must:
  • Be present for at least 6 months.
  • Occur in two or more settings (e.g., home and school).
  • Cause significant impairment in functioning.
  • Be inconsistent with the child’s developmental level.
  • Have started before age 12.

Next Steps:

1. Share this completed questionnaire with a healthcare professional, such as a pediatrician, child psychologist, or psychiatrist, for a comprehensive evaluation.
2. The professional may use additional tools, such as teacher reports, behavioral observations, or standardized tests (e.g., Conners’ Rating Scales), to confirm a diagnosis.
3. Discuss potential interventions, which may include behavioral therapy, school accommodations, medication, or complementary approaches like Ayurveda (see previous responses for Ayurvedic treatment options).
4. Consider consulting an Ayurvedic practitioner for a holistic approach, ensuring coordination with conventional medical care.

Note: ADHD symptoms can overlap with other conditions (e.g., anxiety, learning disabilities, or sensory processing issues). A thorough evaluation is essential to rule out alternative or co-occurring conditions.

Disclaimer

This questionnaire is for informational purposes only and does not replace a professional diagnosis. ADHD diagnosis requires a comprehensive assessment by a qualified healthcare provider, considering medical, developmental, and psychosocial factors. Always consult a professional before pursuing treatment.