adult rating scale 2 - Central Washington University
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Process for AD/HD Assessment 1. The student is given the AD/HD Assessment Packet which includes: Adult Intake Questionnaire (AIQ) Parent retrospective Report (PRR) Parent/Childhood ADHD Rating Scale Adult rating Scale 2 (ARS 2) The AIQ, PRR and the Parent/Child ADHD Rating Scale must be completed before the first appointment is scheduled. The ARS 2 must be completed by someone who knows the student, i.e. roommate, significant other, best friend, etc.. 2. Please make every attempt to bring in report cards from K-12. Copies are fine. All will be returned back to you. You may have to call your high school to get your records. 3. Also, bring in a couple examples of current schoolwork (term papers, test with scores etc..) 4. The initial appointment will be scheduled after the AD/HD Assessment Packet has been completed and returned to the Counseling Center. 5. At your appointment we will continue to screen for AD/HD with several diagnostic tools. These will include the Brown AD/HD Scales, and the Adult Rating Scale 1. There are times when the Conners’ Continuous Performance Test will also be suggested by your Counselor. 6. At the end of your Initial appointment, the Counselor will determine if further assessment is clinically indicated. 3-4 additional, consecutive weekly appointments will then be scheduled by the Counselor. 7. At the final appointment your Counselor will discuss the assessment findings and treatment options with you. Academic accommodations will also be discussed with you at this time if appropriate. If you miss a scheduled appointment and a waiting list exists, your name will be placed at the bottom of the waiting list (and the rest of your scheduled appointments will be canceled). 06/11 M. Anderson ADULT INTAKE QUESTIONNAIRE (For ADD/ADHD Assessment) In order for us to be able to fully evaluate you, please fill out the following questionnaire to the best of your ability. We realize there may be information that you do not remember or have access to; do the best you can. Thank you! PATIENT IDENTIFICATION Name: ____________________________ Date: _______________ Birthday: __________________________ Age: ____________ Sex ______________ Relationship Status: _________________ Children: __________________________ Address: _____________________________________________________________________ City: _____________________________________ State: ______________ Zip: ____________ Home Phone #: ____________________________ Work #: ____________________________ REFERRAL SOURCE Referral Source: _______________________________________________________________ Referral Address: _______________________________________ Phone: ________________ PURPOSE OF THE CONSULTATION (Please give a brief summary of your main problems) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ WHY DID YOU SEEK THE EVALUATION AT THIS TIME? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PRIOR ATTEMPTS TO CORRECT PROBLEMS/PRIOR PSYCHIATRIC HISTORY (Please include with other professionals, medications, types of treatment, etc.) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ MEDICAL HISTORY Current medical problems/medications: _____________________________________________ ______________________________________________________________________________ Past medical problems/medications: ________________________________________________ ______________________________________________________________________________ Other doctors/clinics seen regularly: ________________________________________________ ______________________________________________________________________________ Any history of head trauma? (describe): _____________________________________________ ______________________________________________________________________________ Ever had any seizures or seizure-like activity: _________________________________________ Any periods of spaciness or confusion? ______________________________________________ Prior abnormal lab tests, X-rays, EEG, etc.: ___________________________________________ ______________________________________________________________________________ Allergies/drug intolerances (describe): ______________________________________________ ______________________________________________________________________________ CURRENT LIFE STRESSES (Include anything that is currently stressful for you. Examples include relationship, job, school, finances, children, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ FAMILY STRUCTURE/HISTORY Family Structure (Who do you currently live with?): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Significant Development Events (Including marriages, separations, divorces, death, traumatic event, losses, abuse, etc.) ________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Current Relationship Situation: ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ History of Past marriages or Significant Relationships: _________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Were you adopted? _____________________________________________________________ Please take the time to consult with your parents regarding their history and any known suspected mental health history for members of the extended family (those related by blood). Natural Mother’s History- Age: _____________ Employed as: ________________________ School- highest grade completed: __________________________________________________ Learning problems (specify): ______________________________________________________ Behavior problems (specify): ______________________________________________________ Marriages: ____________________________________________________________________ Medical problems: ______________________________________________________________ Childhood atmosphere (family positions, abuse, illness, etc.): ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ Has mother ever sought psychiatric treatment? Yes _______________ No _________________ If yes, for what purpose? _________________________________________________________ ______________________________________________________________________________ Mother’s alcohol/drug use history: _________________________________________________ Have any of mother’s blood relatives ever had any learning problems or psychiatric problems; including such things as alcohol/drug, depression, anxiety, suicide attempts, psychiatric hospitalization, etc.? (specify): _____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Natural Father’s History- Age: _____________ Employed as: ________________________ School- highest grade completed: __________________________________________________ Learning problems (specify): ______________________________________________________ Behavior problems (specify): _____________________________________________________ Marriages: ____________________________________________________________________ Medical problems: ______________________________________________________________ Childhood atmosphere (family positions, abuse, illness, etc.): ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ Has father ever sought psychiatric treatment? Yes ________________ No _________________ If yes, for what purpose? _________________________________________________________ ______________________________________________________________________________ Father’s alcohol/drug use history: _________________________________________________ Have any of mother’s blood relatives ever had any learning problems or psychiatric problems; including such things as alcohol/drug, depression, anxiety, suicide attempts, psychiatric hospitalization, etc.? (specify): _____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Siblings (name, ages, problems, strengths, relationship to patient) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Children (names, ages, problems, strengths): _________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ EDUCATIONAL HISTORY Last grade complete: ____________________ Last school attended: ______________________ Average grades received: _________________________________________________________ Any academic problems: _________________________________________________________ Learning strengths: ______________________________________________________________ Any behavior problems in school? __________________________________________________ In general, what would your teacher have said about you? ______________________________ ______________________________________________________________________________ ______________________________________________________________________________ EMPLOYMENT HISTORY (summarize jobs you’ve had, list most favorite and least favorite) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Any work-related problems? ______________________________________________________ What would your employers or supervisors have said about you? ________________________ ______________________________________________________________________________ Military History: ________________________________________________________________ ______________________________________________________________________________ Any Legal Problems? ____________________________________________________________ ______________________________________________________________________________ ALCOHOL AND DRUG HISTORY Please list age started and types of substances used through the years and any current usage. Also, describe how each of the substances made you feel; what benefit you got from them. These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc), cocaine or crack, amphetamines, crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms), PCP, etc. (list these on the next page) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Ever experience withdrawal symptoms from alcohol or drugs? ___________________________ Has anyone ever told you they thought you had a problem with alcohol or drugs? ___________ Have you ever felt guilty about your drug or alcohol use? _______________________________ Have you ever felt annoyed when someone talked to you about your drug or alcohol use? ____ Have you ever used drugs or alcohol first thing in the morning? __________________________ Caffeine use per day (caffeine is in coffee, tea, sodas, chocolate, etc.) _____________________ Circle symptoms that apply to you: Restlessness, nervousness, excitability, insomnia, flushed face, frequent urination, upset stomach, muscle twitching, rambling thoughts or speech, heart pounding or racing, easily fatigued, irritability Nicotine use per day, past and present (nicotine is in cigarettes, cigars, tobacco chew, etc.) ____ ______________________________________________________________________________ ______________________________________________________________________________ Cultural/Ethic Background _______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe your relationships with friends ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe yourself _______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your goals in seeking this consultation? What do you hope to gain? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PARENT RETROSPECTIVE REPORT Client Name: ______________________________ Completed by: Mother _____ Father _____ Date: ___________________________ Other _____ Relationship: _______________ INSTRUCTIONS: Your son/daughter is requesting an evaluation at this clinic. As part of the evaluation, we are requesting an evaluation at this clinic. As part of the evaluation, we are requesting that you complete this questionnaire as best you can. The information you provide is very important in our efforts, and your cooperation is appreciated. INFANCY Were any of the following problems present Did your child seem to develop more slowly during your child’s first few years of life: than other children in the following areas: (Circle one answer for each question) (Circle one answer for each question) Did not enjoy cuddling Yes No Walking Yes No Difficult to comfort Yes No Talking Yes No Colic Yes No Riding a bike Yes No Excessive restlessness Yes No Learning to skip Yes No Excessive irritability Yes No Learning to throw or catch Yes No Excessive crying Yes No Excessive shyness Yes No Birth weight: _________ Did your child have a difficult or premature birth? _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ TEMPERAMENT/MOOD Please rate the following behaviors of your child up to 5 years of age. Activity level – How active was your child from an early age? ____________________________ ______________________________________________________________________________ Distractibility – How well did your child pay attention? _________________________________ ______________________________________________________________________________ Play – How well was your child able to play alone without constantly needing your attention? ______________________________________________________________________________ ______________________________________________________________________________ Adaptability – How well did your child deal with transition and change? ___________________ ______________________________________________________________________________ Mood – What was your child’s basic mood? __________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did your child, as a youngster or teen, at any time, display/experience severe mood shifts or seem significantly depressed, irritable, violent, or super-energized? Please describe in detail. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are there any members of your extended family, related by blood, (including past generations) who have been diagnosed with, or suspected of having: ADHD/ADD, Learning Disabilities, Bipolar Disorder (manic-depression), Depression, Anxiety, Schizophrenia, Obsessive Compulsive Disorder, Asperger’s Syndrome, or Tourette’s (or anyone who has attempted/completed suicide, any hospitalization for mental issues, extremely moody, really high energy all the time?) ________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did you ever notice that your child would talk too much or too loudly, or would talk quickly, shifting from topic to topic and not be able to be redirected? Please describe the intensity and how often it would occur. ___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did your child engage in dangerous or risky behavior, often make poor judgments, or act impulsively? Please describe. _____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did your child ever experience visual or auditory hallucinations, severe thought distortion, or tyrannical behavior? Was your child oppositional? ___________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Would your child become more active in the evening; becoming troublesome or having ‘fits’? Did your child have nightmares or night terrors, trouble sleeping, insomnia? How was your child in the morning upon waking? Please describe. __________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did your child seem more ‘cruel’ than other children or have more trouble than other children in understanding the feelings of others? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SCHOOL HISTORY Please indicate whether your child had any of the following school experience (circle one answer for each question). Was retained a grade in school Yes No Difficulty with reading Yes No Difficulty with math Yes No Received poor grades Yes No Disliked doing homework Yes No Disliked going to school Yes No Had behavior problems in school Yes No Was tested for special education Yes No If yes to any of the above, please describe the problems. _______________________________ ______________________________________________________________________________ ______________________________________________________________________________ PROFESSIONALS CONSULTED Did you consult with any clinician for any concerns you may have had about your child’s behavior or school progress? Yes No If yes, please describe your child’s problems you sought help for. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PARENT CHILDHOOD ADHD RATING SCALE Patient’s Name: _________________________ Date: __________________ Parent’s Name: _________________________ Circle the number in the one column which best describes your son/daughter as a child (ages 5 to 12). Not at all Just a Little Pretty Much Very Much 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 1. Often failed to give close attention to details or made careless mistakes 2. Had difficulty sustaining attention in tasks or activities 3. Often did not seem to listen 4. Did not follow through in instructions and failed to finish school work and chores 5. Often had difficulty organizing tasks and activities 6. Often avoided or disliked doing schoolwork or homework 0 1 2 3 7. Often lost or misplaced things (i.e. toys, school assignments, books, pencils, etc.) 0 1 2 3 8. Was easily distracted 0 1 2 3 9. Was often forgetful 0 1 2 3 10. Was often fidgety or squirming in seat 0 1 2 3 11. Had difficulty remaining seated 0 1 2 3 12. Often ran about and climbed excessively in inappropriate situations 0 1 2 3 13. Often had difficult playing quietly 0 1 2 3 14. Often “on the go” or acted if driven by a motor 0 1 2 3 15. Often talked excessively 0 1 2 3 16. Often blurted out answers before questions had been completed 0 1 2 3 17. Had difficulty awaiting turn 0 1 2 3 18. Often interrupted or intruded on others (i.e. butted into conversations or games) 0 1 2 3 ADULT RATING SCALE 2 Your name: _________________________________ Date: ___________________ Name of individual under evaluation: _______________________________________________ Relationship to this individual: Parent Spouse Employer Friend Other ______________ Below is a list of behaviors or problems that some people have. To the right of each item indicate, in your opinion, how much of a problem each one is for the individual under evaluation. Please be sure to provide an answer to each question. Not at all Just a little Pretty Much Very Much 1. Physical restlessness, excessive fidgeting 2. Difficulty concentrating 3. Easily distracted 4. Impatient 5. “Hot” or explosive temper 6. Unpredictable behavior 7. Shifts often from on uncompleted task to another 8. Difficulty completing tasks 9. Impulsive 10. Talks excessively 11. Often interrupts others 12. Often loses things 13. Forgets to do things 14. Engages in physically daring activities, reckless 15. Always on the go, difficulty sitting still 16. Does not appear to listen to others when spoken to 17. Difficulty sustaining attention 18. Difficulty doing things alone 19. Frequently gets into trouble with the law 20. Difficulty delaying gratification 21. Lack of organization skills 22. Inconsistent work/school performance 23. Inability to establish and maintain a routine 24. Performing below level of competence in work/school 25. Overexcitability Lisa L. Weyandt, Ph.D., Central Washington University, Ellensburg, WA 98926 (509) 963-2381 Ext 3688
