CHILDHOOD BEHAVIOUR SCALE – SELF REPORT

Please select the appropriate description that best describes your behaviour when you were a child.PLEASE RATE YOUR BEHAVIOUR BETWEEN 7 and 12 YEARS OF AGE

Name

First Last

1. Failed to give close attention to details or made careless mistakes in my work*

Never/Rarely
Sometimes
Often
Very often

2. Fidgeted with hands or feet or squirmed in seat*

Never/Rarely
Sometimes
Often
Very often

3. Had difficulty my sustaining attention in tasks or fun activities*

Never/Rarely
Sometimes
Often
Very often

4. Left my seat in classroom or other situations in which sitting was expected*

Never/Rarely
Sometimes
Often
Very often

5. Didn’t listen when spoken to directly*

Never/Rarely
Sometimes
Often
Very often

6. Restless in the “squirmy” sense*

Never/Rarely
Sometimes
Often
Very often

7. Didn’t follow through on instructions and failed to finish work*

Never/Rarely
Sometimes
Often
Very often

8. Had difficulty engaging in leisure activities or doing fun things quietly*

Never/Rarely
Sometimes
Often
Very often

9. Had difficulty organising tasks and activities*

Never/Rarely
Sometimes
Often
Very often

10. Felt “on the go all the time” or acted as if “driven by a motor”*

Never/Rarely
Sometimes
Often
Very often

11. Avoided, disliked, or was reluctant to engage in work that required sustained mental effort*

Never/Rarely
Sometimes
Often
Very often

12. Talked excessively*

Never/Rarely
Sometimes
Often
Very often

13. Lost things necessary for tasks or activities*

Never/Rarely
Sometimes
Often
Very often

14. Blurted out answers before questions had been completed*

Never/Rarely
Sometimes
Often
Very often

15. Easily distracted*

Never/Rarely
Sometimes
Often
Very often

16. Had difficulty awaiting turn*

Never/Rarely
Sometimes
Often
Very often

17. Forgetful in daily activities*

Never/Rarely
Sometimes
Often
Very often

18. Interrupted or intruded on others*

Never/Rarely
Sometimes
Often
Very often

Areas of life activities

To what extent did the problems you may have circled on the previous page interfere with your ability to function in each of these areas of life activities when you were a child between 7 and 12 years of age?

19. In your home life with immediate family*

Never/Rarely
Sometimes
Often
Very often

20. In your social interactions with other children*

Never/Rarely
Sometimes
Often
Very often

21. In your activities or dealings in the community*

Never/Rarely
Sometimes
Often
Very often

22. In school*

Never/Rarely
Sometimes
Often
Very often

23. In sports, clubs, or other organisations*

Never/Rarely
Sometimes
Often
Very often

24. In learning to take care of themselves*

Never/Rarely
Sometimes
Often
Very often

25. In your play, leisure or recreational activities*

Never/Rarely
Sometimes
Often
Very often

25. In your handling of daily chores or other responsibilities*

Never/Rarely
Sometimes
Often
Very often