CURRENT BEHAVIOUR SCALE – PARTNER or CLOSE FRIEND

Please select the appropriate description that best describes the behaviour of your PARTNER or CLOSE FRIEND. PLEASE RATE BEHAVIOUR BASED ON THE PAST 6 MONTHS

Name of your PARTNER or CLOSE FRIEND*

First Last

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

Never/Rarely
Sometimes
Often
Very often

2. Fidgets with hands or feet or squirms in seat*

Never/Rarely
Sometimes
Often
Very often

3. Has difficulty sustaining attention in tasks or fun activities*

Never/Rarely
Sometimes
Often
Very often

4. Leaves seat situations in which sitting was expected*

Never/Rarely
Sometimes
Often
Very often

5. Appears not to listen when spoken to directly*

Never/Rarely
Sometimes
Often
Very often

6. Appears restless*

Never/Rarely
Sometimes
Often
Very often

7. Does not follow through on instructions and fails to finish work*

Never/Rarely
Sometimes
Often
Very often

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

Never/Rarely
Sometimes
Often
Very often

9. Has difficulty organising tasks and activities*

Never/Rarely
Sometimes
Often
Very often

10. Appears to be “on the go all the time ” or as if “driven by a motor”*

Never/Rarely
Sometimes
Often
Very often

11. Avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort*

Never/Rarely
Sometimes
Often
Very often

12. Talks excessively*

Never/Rarely
Sometimes
Often
Very often

13. Loses things necessary for tasks or activities*

Never/Rarely
Sometimes
Often
Very often

14. Blurts out answers before questions had been completed*

Never/Rarely
Sometimes
Often
Very often

15. Easily distracted*

Never/Rarely
Sometimes
Often
Very often

16. Has difficulty awaiting turn*

Never/Rarely
Sometimes
Often
Very often

17. Forgetful in daily activities*

Never/Rarely
Sometimes
Often
Very often

18. Interrupts or intrudes on others*

Never/Rarely
Sometimes
Often
Very often

Areas of life activities

To what extent do the problems you may have circled on the previous page interfere with your partner’s/close friend's ability to function in each of these areas of life activities?

19. In his/her home life with immediate family*

Never/Rarely
Sometimes
Often
Very often

22. In his/her work or occupation*

Never/Rarely
Sometimes
Often
Very often

20. In his/her social interactions with others*

Never/Rarely
Sometimes
Often
Very often

21. In his/her activities or dealings in the community*

Never/Rarely
Sometimes
Often
Very often

23. In any educational activities*

Never/Rarely
Sometimes
Often
Very often

24. In your/their dating or marital relationship*

Never/Rarely
Sometimes
Often
Very often

24. In his/her management of money*

Never/Rarely
Sometimes
Often
Very often

24. In his/her ability to drive a motor vehicle*

Never/Rarely
Sometimes
Often
Very often

25. In his/her play, leisure or recreational activities*

Never/Rarely
Sometimes
Often
Very often

25. In his/her handling of daily chores or other responsibilities*

Never/Rarely
Sometimes
Often
Very often