ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Relationship status Please tick:
Single
Married
Divorced
Separated
Widowed
Living with partner
In relationship but not living together
Prefer not to answer
Adult ADHD pathway pre-
assessment questionnaire
Please complete this questionnaire and return it to us before your initial appointment in the
stamped addressed envelope provided. Providing this information will help us to know more
about you and reduce the amount of questions we need to ask during your appointment.
Please note all information is strictly confidential.
Instructions for completing the questionnaire
Please tick any YES/NO questions and answer all questions, providing additional details where
necessary. If you are unable to complete the questionnaire, or would like a member of the
team to support you, please contact us on 01924 316490 and we will be happy to help.
Contact information
Name
Address
Daytime telephone number
Mobile telephone number
Email address
Please provide the name of your next of kin
Contact telephone number/address of your next of kin
Your personal information
Date of birth
Place of birth
Current relationship status
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Would you like your carer to be contacted and involved in your care from our service?
Yes No
Please give the details of everyone living with you/at your address
Current accommodation status
Accommodation status Please tick:
Living alone
Living with partner
Living with parents
Sheltered/temporary accommodation
No fixed address
Other (please specify):
Do you have a carer? Yes No
If yes, name and address of your carer
Name Gender Date of birth Relationship to
you (eg. wife,
daughter, adopt-
ed son etc.)
Details of any mental
health/physical health/
other diagnoses
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Disability Living Allowance/PIP
Employment Support Allowance
Housing Benefit
Other (please give details)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Have you ever been investigated by the Police or charged with a criminal offence?
(e.g. cautions/convictions/court appearances/imprisonment)
Are you currently receiving any of the following benefits?
If yes, please give further details including charges and dates:
What type of school did you attend?
Have you ever received a Statement of Special Educational Needs (SEN) or had an Educational
Health Care Plan (EHCP) during your education?
Education
School type Please tick:
Mainstream state school
Mainstream private school
School for children with behavioural and/or emotional difficulties
Specialist school for children with autism
School for children with severe learning disabilities
School for children with moderate learning disabilities
School for children with physical disabilities and/or sensory impairments
Language unit within a school
Other (please specify):
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Please state your highest level of qualification to date:
Qualification Please tick:
O level/CSE/GCSE
AS Level
A Level
BTEC or equivalent
NVQ
Higher National Diploma
First degree or equivalent professional qualification
Higher degree (e.g. Masters, PhD)
Other (please give details):
Employment
Are you currently in paid employment?
Please give a brief list of your past employment to date and why you left:
Yes No
Dates (year) Company Job title Type of work Why you left
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Family structure
Please complete the following information about your mother:
Name
Is she: Living Deceased
Age
Occupation
Has your mother ever been diagnosed with a mental health condition or other diagnosis?
Please complete the following information about your (birth) father:
Name
Is he: Living Deceased
Age
Occupation
Has your father ever been diagnosed with a mental health condition or other diagnosis?
If yes, please could you give us some details?
If yes, please could you give us some details?
Has your mother ever been diagnosed with any physical health conditions?
Has your father ever been diagnosed with any physical health conditions?
If yes, please could you give us some details?
If yes, please could you give us some details?
Yes No
Yes No
Yes No
Yes No
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Do you have any children who do not live with you?
Do you have any brothers or sisters?
If yes, please complete the following information for each of your children.
If yes, please complete the following information for each of your siblings.
Yes No
Yes No
Name Gender Date of birth Living or
deceased
Details of any mental health/
physical health/other diagnoses
Name Gender Date of birth Living or
deceased
Details of any mental health/
physical health/other diagnoses
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Please could you give information about any other family details you think may be relevant?
(e.g. stepchildren, previous marriages, adoptions, foster care, other family members such as
grandparents who may have a mental health condition):
Please give details of any allergies and the current medication you have been prescribed for
either mental health and/or physical health reasons. Please include name, dosage and what it
Name and address of your GP
Do you:
Medical history
Allergies:
Allergic to:
What happens when exposed
Smoke cigarettes/tobacco?
If yes, how many cigarettes do you smoke a day?
Smoke cannabis?
If yes, how much cannabis do you smoke each day? (e.g. number of joints, ounces of cannabis)
Current medication
Yes No
Yes No
1-5 5-10 10-15 15-20 20+
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Do you have any diagnosed physical health conditions?
Have you ever felt suicidal?
If yes, have you ever planned or attempted suicide?
If yes, please give some details:
Have you ever been diagnosed with the following?
If yes, please give details:
Autism spectrum disorder (including Asperger’s)
Tourette’s syndrome
Obsessive compulsive disorder (OCD)
(General) Anxiety disorder
Depression
Dyspraxia
Dyslexia
Dyscalculia
Learning disability or global developmental delay
Any genetic disorder
Sleep disorder
Visual problems
Hearing problems
Language delay or other language disorders
Schizophrenia
Bipolar disorder
Personality disorder
Substance misuse
Any other mental health condition
If yes, please give details:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Have you ever been referred to any other of the following professionals?
Please give the names and addresses of any other clinicians or services you have seen
(either in the past or currently for mental health or social care reasons (including social
workers, probation officers, etc.):
Psychiatrist
Clinical psychologist
Educational psychologist
Forensic psychologist
Nurse
Speech and language therapist
Occupational therapist
Social worker
Probation officer
Support worker
Disability employment advisor
Other (give details)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Name Profession/service Date seen Current or past involvement
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Health and wellbeing screening
Health
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Please mark your answer with a tick)
If you ticked any of the problems above, how difficult have these made it for you to do your
work, take care of things at home, or get along with other people?
Problem
Not at
all
Several
days
More
than half
the days
Nearly
every day
1
Little interest or pleasure in doing things
2
Feeling down, depressed, or hopeless
3
Trouble falling or staying asleep, or sleeping too
much
4
Feeling tired or having little energy
5
Poor appetite or overeating
6
Feeling bad about yourself – or that you are a
failure or have let yourself or your family down
7
Trouble concentrating on things, such as reading
the newspaper or watching television
8
Moving or speaking so slowly that other people
could have noticed. Or the opposite – being so
fidgety or restless that you have been moving
around a lot more than usual
9
Thoughts that you would be better off dead, or
of hurting yourself in some way
10
Feeling nervous, anxious or on edge
11
Not being able to stop or control worrying
12
Worrying too much about different things
13
Trouble relaxing
14
Being so restless that it is hard to sit still
15
Becoming easily annoyed or irritable
16
Feeling afraid as if something awful might hap-
pen
Not difficult at all Somewhat difficult Very difficult Extremely difficult
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Mood
Please answer each question to the best of your ability. (Please mark your answer with a tick)
1. Has there ever been a period of time when YOU WERE NOT YOUR USUAL SELF and…
3. How much of a problem did any of these cause you – like being unable to work; having
family, money or legal troubles; getting into arguments or fights?
Yes No
…you felt so good or so hyper that other people thought you were not
your normal self or you were so hyper that you got into trouble?
…you were so irritable that you shouted at people or started fights or
arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn’t really miss it?
…you were much more talkative or spoke much faster than usual?
…thoughts raced through your head or you couldn’t slow your mind
down?
…you were so easily distracted by things around you that you had trouble
concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual, for example, you
telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might
have thought were excessive, foolish, or risky?
…spending money got you or your family into trouble?
Yes No
4. Have any of your blood relatives (i.e. children, siblings, parents, grand-
parents, aunts, uncles) had manic-depressive illness or bipolar disorder?
5. Has a health professional ever told you that you have manic-depressive
illness or bipolar disorder?
Yes No
2. If you ticked YES to more than one of the above, have several of these
ever happened during the same period of time?
No problem Minor problem Moderate problem Severe problem
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Alcohol
(please tick the answer that is correct for you)
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have six or more drinks on one occasion?
4. How often during the last year have you found it difficult to get the thought of alcohol
out of your mind?
5. How often during the last year have you found that you were not able to stop drinking
once you had started?
6. How often during the last year have you been unable to remember what happened the
night before because you had been drinking?
7. How often during the last year have you needed an alcoholic first drink in the morning
to get yourself going after a heavy drinking session?
8. How often during the last year have you had a feeling of guilt or remorse after drinking?
9. Have you or someone else been injured as a result of your drinking?
10. Has a relative, friend, doctor or any other health worker been concerned about your
drinking or suggested you cut down?
Never Monthly 2-4 times a month 2-3 times a week 4 or more times a
week
Never Less than monthly Monthly Weekly Daily or almost daily
Never Less than monthly Monthly Weekly Daily or almost daily
Never Less than monthly Monthly Weekly Daily or almost daily
Never Less than monthly Monthly Weekly Daily or almost daily
Never Less than monthly Monthly Weekly Daily or almost daily
Never Less than monthly Monthly Weekly Daily or almost daily
No Yes, but not in the last year Yes, during the last year
No Yes, but not in the last year Yes, during the last year
1 or 2 3 or 4 5 or 6 7 to 9 10 or more
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Drugs
These questions refer to the past 12 months (please mark your answer with a tick)
Brain injury (please mark your answer with a tick)
Yes No
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you always able to stop using drugs when you want to?
4. Have you had “blackouts” or “flashbacks” as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your wife/husband (or parent) ever complain about your involve-
7. Have you neglected your family because of your use of drugs?
8. Have you done anything illegal in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you
stopped taking drugs?
10. Have you had medical problems as a result of your drug use (for exam-
ple: memory loss, liver problems, fits, bleeding)?
Yes No
1. Have you ever hit your head or been hit on the head?
2. Were you ever seen in A&E, hospital, or by a doctor because of an injury
to your head?
3.a. Did you ever lose consciousness or experience a period of being dazed
and confused because of an injury to your head?
3.b. If YES, have you experienced any of these problems in your daily life
since you hit your head? Tick whichever applies to you:
Headaches
Dizziness
Anxiety
Depression
Difficulty concentrating
Difficulty remembering
Difficulty reading
Difficulty writing
Difficulty calculating
Poor problem solving
Difficulty performing your job
Change in relationships with others
Poor judgement (being fired from job, arrests, fights)
4. Any significant sicknesses?
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Personality (please mark your answer with a tick)
Yes No
1.a. Some people find their mood changes frequently - as if they spend
every day on an emotional roller coaster. For example, they might switch
from feeling angry to depressed to anxious many times a day. Does this
sound like you?
1.b. If YES, have you been this way most of your life?
2.a. Some people prefer to be the centre of attention, while others are
content to remain on the edge of things. Would you describe yourself as
preferring to be the centre of attention?
2.b. If YES, does it bother you when someone else is in the spotlight?
3.a. Do you frequently insist on having what you want right now, even
when waiting a little longer would get you something much better?
3.b. Do you often get in trouble at work or with friends because you act
excited at first but then lose interest in projects and don't follow through?
4. Do you find that most people will take advantage of you if you let them
know too much about you?
5.a. Do you generally feel nervous or anxious around people?
5.b. Do you avoid situations where you have to meet new people?
6.a. Do you avoid getting to know people because you're worried they
may not like you?
6.b. If YES, has this affected the number of friends that you have?
7.a. Do you keep changing the way you present yourself to people because
you don’t know who you really are?
7.b. Do you often feel like your beliefs change so much that you don't
know what you really believe any more?
8. Do you often get angry or irritated because people don't recognize your
special talents or achievements as much as they should?
9.a. Do you often suspect that people you know may be trying to cheat or
take advantage of you?
9.b. If YES, do you worry about this a lot?
10. Do you tend to hold grudges or give people the silent treatment for
days at a time?
11.a. Do you get annoyed when friends or family complain about their
problems?
11.b. Do people complain that you're not very sympathetic to their prob-
lems?
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Social communication (please mark your answer with a tick)
Yes No
Do you find social situations confusing?
Do you find it hard to make small talk?
Do you find it difficult to ‘read between the lines’ when someone is talk-
ing to you?
When you are reading a story, do you find it difficult to work out the char-
acter’s intentions?
Do people frequently tell you that what you have said is impolite, even
though you think it is polite?
Do you find it difficult to do things in a new way?
When reading a story, do you find it difficult to imagine what the charac-
ters may look like?
Do you find making up stories difficult?
Do you find it difficult to work out what someone is thinking or feeling
just by looking at their face?
Do you do certain things in a very inflexible, repetitive way?
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Your initial appointment with us
Please let us know who will be coming with you to your appointment. Please note, because we
are required to take a full developmental history in order to make an accurate diagnosis, it is
very important that where possible you have someone with you who knew you well as a child.
If you think you may have difficulties with this, please contact the service on 01924 316490.
Name(s)
Are they your mother/father/other (please specify)?
Please find a questionnaire enclosed for you to ask someone who knew you as a child to
complete.
Confidentiality
Anything that is written about a patient or relative is kept strictly confidential and is normally
only seen by people working in the service. However, as part of our day-to-day duties as
clinicians, we are required to record patient notes on an NHS electronic notes system. This
system is protected by the Data Protection Act, and access is monitored and limited to only
those clinicians directly involved in the patient’s care.
We normally send copies of assessment reports to the referrer and your GP. If you would like
yourself or someone else to receive a copy of the report please let us know at one of your
appointments or by contacting us in writing.
Members of staff carry out research and also audit their work. Occasionally, clinicians may wish
to write up details of any treatments or cases for publication. We will always seek the patients’
written consent before this happens. In such cases where material is agreed for publication,
all patient data is completed anonymised and non-identifiable. As part of our work we also
receive regular clinical supervision which means that we will discuss the patient’s case with a
qualified colleague. We also have regular team meetings at the clinic to discuss the progress of
cases within the service. In all such cases, members of staff are bound by patient confidentiality
agreements unless we identify that there is a concern or risk to either the patient or someone
else. We will always seek to discuss this with the patient in the first instance.
Do you consent for your data to be used for research purposes:
Thank you for taking the time to complete this questionnaire. Please check you have
answered all questions before returning it to us.
Yes No
JOB NO 1455 FEB 20
