Texas Barkley Self Report: Current 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 DURING THE PAST 6 MONTHS. Section 1 (Inattention) Fail to give close attention to details or make careless mistakes in my work or other activities * - Never or Rarely Sometimes Often Very Often Difficulty sustaining my attention in tasks or fun activities * - Never or Rarely Sometimes Often Very Often Don't listen when spoken to directly * - Never or Rarely Sometimes Often Very Often Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort * - Never or Rarely Sometimes Often Very Often Lose things necessary for tasks or activities * - Never or Rarely Sometimes Often Very Often Easily distracted by extraneous stimuli or irrelevant thoughts * - Never or Rarely Sometimes Often Very Often Forgetful in daily activities * - Never or Rarely Sometimes Often Very Often Don't follow through on instructions and fail to finish work or chores * - Never Sometimes Often Very Often Have difficulty organizing tasks and activities * - Never 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 Sometimes Often Very Often Leave my seat in classrooms or in other situations in which remaining seated is expected * - Never or Rarely Sometimes Often Very Often Shift around excessively or feel restless or hemmed in * - Never or Rarely Sometimes Often Very Often Have difficulty engaging in leisure activities quietly (feel uncomfortable, or am loud or noisy) * - Never and Rarely Sometimes Often Very Often I am "on the go" or act as if "driven by a motor" (or feel like I have 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 Blurt out answers before questions have been completed, complete others' sentences, or jump the gun * - Never or Rarely Sometimes Often Very Often Have difficulty awaiting my turn * - Never or Rarely Sometimes Often Very Often Interrupt or intrude on others (butt into conversations or activities without permission or take 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. Prone to daydreaming when I should be concentrating on something or working * - Never or Rarely Sometimes Often Very Often Have trouble staying alert or awake in boring situations * - Never or Rarely Sometimes Often Very Often Easily confused * - Never or Rarely Sometimes Often Very Often Easily bored * - Never or Rarely Sometimes Often Very Often Spacey or "in a fog" * - Never or Rarely Sometimes Often Very Often Lethargic * - Never or Rarely Sometimes Often Very Often Underactive or have less energy than others * - Never or Rarely Sometimes Often Very Often Slow moving * - Never or Rarely Sometimes Often Very Often I don't seem to process information as quickly or as accurately as others * - Never or Rarely Sometimes Often Very Often Section 5 Choose one of the options in the menu. For any of the above questions, did you answer "Often" or "Very often"? * - Yes No If so, how old were you 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 your functioning? Select all that apply School Home Work Social Relationships Thank you! Back to Patient Forms
