BAARS IV QUESTIONNAIRE – SELF

This questionnaire forms part of your ADHD assessment. Please select only one answer for each question. Once completed and signed, please send to enquiries@humanmind.health along with the BAARS IV Informant Questionnaire prior to your appointment with the doctor. If you have any questions, please contact us and we will advise.

Name:

Date of Birth: Date Completed:

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30	If so, in which of these settings did those symptoms impair your functioning? Please tick the box next to all of the areas that apply to you. School Home Work Social Relationships
Total Score:0

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Signature: Print Name:

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BAARS-IV Self-Report (Current Symptoms) This form should be completed by the patient.
How often do you experience these 27 symptoms? Please tick the box next to each item below that best describes your behaviour during the past six months.		Never/ Rarely (1)	Some- times (2)	Often (3)	Very Often (4)
Section 1 (Inattention) (Select only ONE option) Score: 0
1	Fail to give close attention to details or make careless mistakes in my work or other activities
2	Difficulty sustaining my attention in tasks or fun activities
3	Don’t listen when spoken to directly
4	Don’t follow through on instructions and fail to finish work or chores
5	Have difficulty organizing tasks and activities
6	Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort
7	Lose things necessary for tasks or activities
8	Easily distracted by extraneous stimuli or irrelevant thoughts
9	Forgetful in daily activities
Section 2 (Hyperactivity) (Select only ONE option) Score: 0
10	Fidget with hands or feet or squirm in seat
11	Leave my seat in classrooms or in other situations in which remaining seated is expected
12	Shift around excessively or feel restless or hemmed in

13	Have difficulty engaging in leisure activities quietly (feel uncomfortable, or am loud or noisy)
14	I am “on the go” or act as if “driven by a motor” (or I feel like I have to be busy or always doing something)
Section 3 (Impulsivity) (Select only ONE option) Score: 0
15	Talk excessively (in social situations)
16	Blurt out answers before questions have been completed, completed others’ sentences, or jump the gun
17	Have difficulty awaiting my turn
18	Interrupt or intrude on others (but into conversations or activities without permission or take over what others are doing).
Section 4 (Sluggish Cognitive Tempo) (Select only ONE option) Score: 0
19	Prone to daydreaming when I should be concentrating on something or working
20	Have trouble staying alert or awake in boring situations
21	Easily confused
22	Easily bored
23	Spacey or “in a fog”
24	Lethargic, more tired than others
25	Underactive or have less energy than others
26	Slow moving
27	I don’t seem to process information as quickly or as accurately as others
Section 5 (Summary) Please answer these three questions as prompted.
28	Did you experience any of these 27 symptoms at least “Often” or “Very Often”? (did you tick an “Often” or “Very Often” above?) Choose an item. Yes No
29	If so, how old were you when these symptoms began? I was years old.

BAARS-IV Self-Report (Childhood Symptoms) This form should be completed by the patient.
Please tick the box next to each item below that best describes your behaviour when you were a child between 5 and 12 years of age.		Never/ Rarely (1)	Some- times (2)	Often (3)	Very Often (4)
Section 1 (Inattention) (Select only ONE option) Score: 0
1	Failed to give close attention to details or made careless mistakes in my work or other activities
2	Has difficulty sustaining my attention in tasks or fun activities
3	Didn’t listen when spoken to directly
4	Didn’t follow through on instructions and fail to finish work or chores
5	Had difficulty organizing tasks and activities
6	Avoided, disliked, or was reluctant to engage in tasks that require sustained mental effort
7	Lost things necessary for tasks or activities
8	Was easily distracted by extraneous stimuli or irrelevant thoughts
9	Was forgetful in daily activities
Section 2 (Hyperactivity-Impulsivity) (Select only ONE option) Score: 0
10	Fidgeted with my hands or feet or squirmed in my seat
11	Left my seat in classrooms or in other situations in which remaining seated was expected
12	Shifted around excessively or felt restless or hemmed in
13	Had difficulty engaging in leisure activities quietly (felt uncomfortable, or was loud or noisy)
14	Was “on the go” or acted as if “driven by a motor”
15	Talked excessively

16	Blurted out answers before questions had been completed, completed others’ sentences, or jumped the gun
17	Had difficulty awaiting my turn
18	Interrupted or intruded on others (butted into conversations or activities without permission or took over what others were doing).
Section 3 (Summary) Please answer these two questions as prompted.
19	Did you experience any of these 18 symptoms at least “Often” or “Very Often”? (did you tick an “Often” or “Very Often” above?) Choose an item. Yes No
20	If so, in which of these settings did those symptoms impair your functioning? Please tick the box next to all of the areas that apply to you. School Home Social Relationships
Total Score:0