Form – History – ADHD Consultancy Limited

First Name

Email

Were your parents married?*

Yes
No
Divorced / separated

Biological father’s occupation*

Biological mother’s occupation*

Number of full/ half siblings and your place*

Any blood relatives showing similar symptoms?*

Were you born by full term normal delivery and well after birth?*

Any delay in sitting up / walking / talking (early milestones)*

Were you an active baby and young child? Any other early characteristics?*

Difficulties in primary school*

Primary school experience*

Academic level at end of primary school (aged 11)*

Describe your secondary school experience up to GCSE. How was it similar or different from primary school?*

Issues prior to GCSE / formal examinations?*

Select All
Struggled to revise
Homework not done/done last minute
Behaviour problems
Achieved potential

How many GCSEs / formal examination passes did you get, with grades?*

Describe your sixth form school or college experience. What exams did you get with grades? Did you achieve your potential?*

Describe University/ further education experience with focus on any problems with attendance, organisation, coursework etc. Grades achieved? Did you achieve your potential?*

Please describe your work history, with a focus on problems, patterns and reasons for leaving. You don’t have to list every job just a general picture including current occupation and future career aims/hopes*

At work, have you had problems with any of the above?*

Select All
Lateness
Too much sick leave
Difficulties learning/remembering processes
Difficulties understanding conversations
Problems getting started and / or finishing projects
Boredom
Problems with rules/authority
Being sacked or asked to leave jobs

Any other workplace issues?

Are you currently married or in a relationship?*

Please describe your relationship history. No need to list everything, just the pattern, longest relationship, any issues and why they end. What do you hope for going forwards?*

Please describe your friendships, with particular focus on any areas of difficulty*

In relationships and/or friendships, do you struggle with: -*

Select All
Shyness
Boredom
Jealousy
Faithfulness
Oversensitivity and / or overthinking
Feeling suffocated or overwhelmed by others

Have you seen psychiatrists before for your mental health, with appropriate details*

Have you struggled much with low mood? Please give some details. Have you ever taken antidepressants or other mental health medications?*

Are you an anxious person? Have you ever had a panic attack?*

Briefly summarise any therapy/ counselling you have had and when. Did it help at all and if so, how?*

Have you ever been in trouble with the law?

Any sleep issues, past or present. Do you use any specific strategies to help with sleep?

Please describe any eating disorders or problems past or present*

Do you have any issues with alcohol or drugs past or present? Current levels of use?*

Do you drive currently?*

If you drive, do you have issues with any of the following when driving?

Select All
Inattentiveness
Accidents
Speeding
Road rage

Are you sensitive to light, noise, smell, touch etc.?*

Yes
No

Please tell us more about any sensitivities you have.

As a child were you clumsy / slower/ worse than others with learning to tie shoelaces, ride a bike etc.?*

Yes
No

As an adult, do you have problems with clumsiness, distinguishing left and right or finding your way around?*

Yes
No

GDPR Consent*

I agree.

I agree that ADHD Consultancy may retain and use my personal information for the purpose of completing your report. We may also use your data in anonymised form in research assessing the benefits of our ADHD treatments but this will not affect your confidentiality.

Comments

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Form – History

Early Life Questionnaire

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