BAARS IV QUESTIONNAIRE – INFORMANT

This questionnaire forms part of the patient's ADHD assessment. Please select only one answer for each question. Once completed and signed, please return to the patient. This form, along with the BAARS IV Self Questionnaire, should be returned by email to enquiries@humanmind.health, prior to the 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 this person’s functioning? Please tick the box next to all of the areas that apply. School Home Work Social Relationships
Total Score:0

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If you checked any of the domains in item 20, above, indicating setting in which symptoms impaired the person’s functioning, please provide examples of those childhood difficulties in the spaces below.
Please feel free to write as much as you need.

School

Home

Social Relationships

Signature: Print Name:

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BAARS-IV Other-Report (Current Symptoms) This form should be completed by someone who knows the patient well.
Your name:
Your relationship to the person being related:
Please tick the box next to each item below that best describes this person’s 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	Fails to give close attention to details or made careless mistakes in their work or other activities
2	Has difficulty sustaining their attention in tasks or fun activities
3	Doesn’t listen when spoken to directly
4	Doesn’t follow through on instructions and fail to finish work or chores
5	Has difficulty organizing tasks and activities
6	Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
7	Loses things necessary for tasks or activities
8	Is easily distracted by extraneous stimuli or irrelevant thoughts
9	Is forgetful in daily activities
Section 2 (Hyperactivity) (Select only ONE option) Score: 0
10	Fidgets with hands or feet or squirms in seat
11	Leaves their seat in classrooms or in other situations in which remaining seated is expected
12	Shifts around excessively or feels restless or hemmed in

13	Has difficulty engaging in leisure activities quietly (feels uncomfortable, or is loud or noisy)
14	Is “on the go” or act as if “driven by a motor” (or they feel like they have to be busy or always doing something)
Section 3 (Impulsivity) (Select only ONE option) Score: 0
15	Talks excessively (in social situations)
16	Blurts out answers before questions have been completed, completes others’ sentences, or jumps the gun
17	Has difficulty awaiting their turn
18	Interrupts or intrudes on others (butts into conversations or activities without permission or takes over what others are doing).
Section 4 (Sluggish Cognitive Tempo) (Select only ONE option) Score: 0
19	Prone to daydreaming when they should be concentrating on something or working
20	Has trouble staying alert or awake in boring situations
21	Is easily confused
22	Is easily bored
23	Is spacey or “in a fog”
24	Is lethargic, more tired than others
25	Is underactive or have less energy than others
26	Is slow moving
27	Doesn’t seem to process information as quickly or as accurately as others
Section 5 (Summary) Please answer these three questions as prompted.
28	Does this person 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 was this person when these symptoms began? They were years old. OR, if you do not know, place a check mark below. I do not know.

BAARS-IV Other-Report (Childhood Symptoms) This form should be completed by someone who knew the patient as a child age 5-12. If the patient does not have someone who can complete this section, it can be left blank.
Your name:
Your relationship to the person being related:
Date completed:
Please tick the box next to each item below that best describes this person’s behaviour when they 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 their work or other activities
2	Had difficulty sustaining their 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 their hands or feet or squirmed in their seat
11	Left their 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 their 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 this person 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 this person’s functioning? Please tick the box next to all of the areas that apply to them. School Home Social Relationships
Total Score:0