CAADID
Part I: History
Elaborated by:
Jeff Epstein, Ph.D.
Diane E. Johnson, Ph.D.
C. Keith Conners, Ph.D.
Demographic information
Your name:______(1)
Age:______(2) Gender: M F (3)
Date of birth:______/ ______/ ______(4)
dd mm yyyy
Home address:______
______
______
______
Date of filling in:______/ ______/ ______(5)
dd mm yyyy
For administrative necessities:Patient #:______(6)
Name of person doing the interview:______(7)
What in your life makes you believe that you have Attention Deficit Hyperactivity Disorder or ADHD?
______
______(8)
Childhood
Letusstartfromthebeginning. With whom were you living when you were a child?
Kinship tie / Name / Age(9)
(11)
(13)
(15)
(17)
(19) / (10)
(12)
(14)
(16)
(18)
(20)
Wherewereyouliving?______(21)
What was your father’s occupation?______(22)
Whatwasyourmother’soccupation?______(23)
Wereyouadopted?YN (24)
If yes, at what age? ______(25)
Riskyfactors related to pregnancy
Has someone ever told you or have you ever heard about any of the following events during your mother’s pregnancy with you?
Disease of the mother (presence of toxic substances in blood, anaemia)
YN (26)
The mother was taking drugsYN (27)
The mother was smoking cigarettesYN (28)
The mother was drinking alcoholic drinks YN (29)
The mother was using prohibited substances YN (30)
Premature birthYN (31)
Was there anything else unusual regarding your mother’s pregnancy?YN (32)
(If yes, please describe it on the lines below.)
______
Riskyfactorsduring child-bearing
Has anything of the following happened to you during child-bearing:
Foetus maladyYN (34)
Low weight at child-bearing(lower than 5 lbs or 2000 grams)YN (35)
Sciatic childbirth by means of forcepsYN (36)
Staying in hospital longer than the expected period YN (37)
Anoxia(oxygen insufficiency, blue baby)YN (38)
Was there anything else unusual regarding your birth?YN (39)
(If yes, please describe it on the lines below.)
______
Riskyfactorscaused by temper
As a baby and a child learning how to walk, were your parents or other people describing you as having or did you have any of the following:
With high level of activity, unusually energeticYN (41)
ImpulsiveYN (42)
CowardlyYN (43)
Inclined to incidents YN (44)
With transientattention keepingYN (45)
IrritableYN (46)
With not good adaptation to changes, slowly taking the change YN (47)
With acute stomach-achesYN (48)
With constantirritabletemperYN (49)
With nutrition problems YN (50)
With sleep problemsYN (51)
ClumsyYN (52)
Starchy, and tenseinstead of inclined to hugging YN (53)
Is there something else that could describe you as a baby or a child learning how to walk?
If yes, please describe it on the lines below.)YN (54)
______
Riskyfactors concerninggrowth
Have you ever heard people saying that as a child you
Began to walk later YN (56)
Began to speak later YN (57)
Were accustomed to using toilet with difficulty YN (58)
Began to read later YN (59)
Was there something else unusual regarding your birth?YN (60)
(If yes, please describe it on the lines below.)
______
Riskyfactors of environment
As a child or a teenager have you experienced any of the following things?
Significant loss or separation with someone you loved YN (62)
Sexual abuseYN (63)
Physical abuseYN (64)
Emotional abuse YN (65)
Violence in the family YN (66)
DisregardYN (67)
Unusual stress in the family YN (68)
Economic issues / poverty / financial stress YN (69)
A diet poor in nutrients YN (70)
Exposure on heavy metals YN (71)
Have you experienced other traumas during childhood?YN (72
(If yes, please describe them on the lines below.)
______
______
MedicalRiskyfactors
As a child were you ill with any of the following
AllergiesYesN(74)
AsthmaYN (75)
EncephalitisYN (76)
MeningitisYN (77)
Fits of loss of consciousness / fainting YN (78)
Incidents out of carelessnessYN (79)
Frequent visits of casualty ward YN (80)
Broken bones YN (81)
Hospitalization due to any reasonYN (82)
Loss of consciousnessYN (83)
ConvulsionsYN (84)
Did you have any other medical issues in childhood?YN (85)
(If yes, please describe them on the lines below.)
______
______
History of elementary education
What elementary school did you attend? ______(87)
During elementary education were you in general (select one)(88)
а) usually above basic levelb) normal – working on basic level
c) under basic leveld) needing additional assistance
(for instance assistance at learning)
During elementary education did any of the following things happen to you?
Unsuccessful passing into another gradeYN (89)
Repeating gradeYN (90)
Taking extra classesYN (91)
Estimated by schoolYN (92)
A “label” was put on you by schoolYN (93)
Difficulties in learning YN (94)
Advisory assistance received YN (95)
Restrained from attending schoolYN (96)
Expelled from school YN (97)
Reading problemsYN (98)
Calculation problems YN (99)
Writing problemsYN (100)
Your work was uncertain or unpredictable YN (101)
Have you been told that you were not realizing your potential YN (102)
Have you been told that you have disability for learning YN (103)
Did other significant events happen to you during the period of your elementary education?
(If yes, please describe them on the lines below.)YN (104)
______
History of second education
What secondary school did you attend?______(106)
What secondary school did you attend?______(107)
During secondary education were you in general (select one)(108)
а) usually above basic levelb) normal – working on basic level
c) under basic leveld) needing additional assistance
(for instance assistance at learning)
During elementary and secondary education did any of the following things happen to you?
Unsuccessful passing into another gradeYN (109)
Repeating gradeYN (110)
Taking extra classesYN (111)
Estimated by schoolYN (112)
A “label” was put on you by schoolYN (113)
Difficulties in learningYN (114)
Advisory assistance receivedYN (115)
Restrained from attending schoolYN (116)
Expelled from schoolYN (117)
You did not graduateYN (118)
Reading problemsYN (119)
Calculation problemsYN (120)
Writing problemsYN (121)
Your work was uncertain or unpredictableYN (122)
You have been told that you were not realizing your potentialYN (123)
You have been told that you have disability for learningYN (124)
Did other significant events happen to you during the period of your secondary education?
(If yes, please describe them on the lines below.)YN (125)
______
History of mental disease
As a child or a teenager were you diagnosticated with Attention Deficit Hyperactivity Disorder or Attention Deficit Syndrome? Y N (127)
As a child have you ever visited due to any reasons a professional like social worker, psychologist or psychiatrist? Y N (128)
Expert 1 / Expert 2 / Expert 3For what kind of problems? / (129) / (130) / (131)
What kind of expert? / (132) / (133) / (134)
Expert’s name / (135) / (136) / (137)
At what age did you start attending
him? / (138) / (139) / (140)
At what age did you stop attending
him? / (141) / (142) / (143)
How often? / (144) / (145) / (146)
Benefits / (147) / (148) / (149)
Reason for cessation / (150) / (151) / (152)
Expert 4 / Expert 5 / Expert 6
For what kind of problems? / (153) / (154) / (155)
What kind of expert? / (156) / (157) / (158)
Expert’s name / (159) / (160) / (161)
At what age did you start attending
him? / (162) / (163) / (164)
At what age did you stop attending
him? / (165) / (166) / (167)
How often? / (168) / (169) / (170)
Benefits / (171) / (172) / (173)
Reason for cessation / (174) / (175) / (176)
Have you undergone a course of treatment for any psychological / mental problem?
Treatment 1 / Treatment 2 / Treatment 3Drug’s name / (177) / (178) / (179)
Prescribed by / (180) / (181) / (182)
At what age did you start? / (183) / (184) / (185)
At what age did you stop? / (186) / (187) / (188))
For what problems? / (189) / (190) / (191)
Total dose per day? / (192) / (193) / (194)
Benefits / (195) / (196) / (197)
Side effects / (198) / (199) / (200)
History of risky factors related to family
Do you think that any of your closest relatives (for example parents, brothers or sisters, or your children) is possible to have or to have had АDHDwhether he/she has been diagnosticated/treated or not? If yes, who?
Relationship with patient / Diagnosticated? / Treated?______(201)
______(204)
______(207)
______(210) / Y N (202)
Y N (205)
Y N (208)
Y N (211) / Y N (203)
Y N (206)
Y N (209)
Y N (212)
Do you think that other relatives of yours (for example aunts, uncles, cousins, nieces, nephews) are possible to have АDHD?If yes, who?
Relationship with patient / Diagnosticated? / Treated?______(213)
______(216)
______(219)
______(222) / Y N (214)
Y N (217)
Y N (220)
Y N (223) / Y N (215)
Y N (218)
Y N (221)
Y N (224)
Does any of your relatives have any of the following psychological / mental disorders?
Disorder / Present? / Relationship with patientDepression
Maniacal depression
(orBipolardisorder)
Anxiety or strong inconvenience
Addition to alcoholic drinks
Other addiction to substances
Making problems or troubles with law
Problems with learning / Y N 225)
Y N (227)
Y N (229)
Y N (231)
Y N (233)
Y N (235)
Y N (237) / ______(226)
______(228)
______(230)
______(232)
______(234)
______(236)
______(238)
Mature age
History of education
These questions concern 18-year old persons.
Have you attended or do you attend any post-secondary school (for example a college or technical school)? Y N (239)
School / Dates / Specialty / Average results / Graduated? / Degree obtained______(240)
______(246)
______(252)
______(258)
______(264)
______(270) / _____ (241)
_____ (247)
_____ (253)
_____ (259)
_____ (265)
_____ (271) / ______(242)
______(248)
______(254)
______(260)
______(266)
______(272) / _____ (243)
_____ (249)
_____ (255)
_____ (261)
_____ (267)
_____ (273) / ______(244)
______(250)
______(256)
______(262)
______(268)
______(274) / ______(245)
______(251)
______(257)
______(263)
______(269)
______(275)
Employment history
What was your occupation after you finished your secondary education?
Job / Dates / Responsibilities / Why /how did it end?______(276)
______(280)
______(284)
______(288)
______(292)
______(296)
______(300)
______(304) / ______(277)
______(281)
______(285)
______(289)
______(293)
______(297)
______(301)
______(305) / ______(278)
______(282)
______(286)
______(290)
______(294)
______(298)
______(302)
______(306) / ______(279)
______(283)
______(287)
______(201)
______(295)
______(299)
______(303)
______(307)
Social/ interpersonalhistory
At the present time who lives in your house?
Relationship / Name / Present age______(308)
______(311)
______(314)
______(317)
______(320) / ______(309)
______(312)
______(315)
______(318)
______(321) / ______(310)
______(313)
______(316)
______(319)
______(322)
Describe the children who live out of your house:
Relationship / Name / Present age______(323)
______(326)
______(329)
______(332)
______(335) / ______(324)
______(327)
______(330)
______(333)
______(336) / ______(325)
______(328)
______(331)
______(334)
______(337)
Have you been married?YN (338)
If yes,to whom?
Name of partner / Dates / Why /how did it end?______(339)
______(342)
______(345)
______(348)
______(351) / ______(340)
______(343)
______(346)
______(349)
______(352) / ______(341)
______(344)
______(347)
______(350)
______(353)
How many significant intimate relations did you have as a grown-up?______(354)
State of health
At the present time are you in good health? YN (355)
When was the last time you visited a doctor for examination?______(356)
Did you have specific chronicdiseases?YN (357)
If you answer yes, please describe them below.)
- ______
- ______
- ______
- ______
Atthemomentareyouundertreatmentfor any diseases?YN (362)
If yes, please describe them below:
Treatment1 / Treatment2 / Treatment3Drug’s name
For what problem?
Dose / ______(363)
______(366)
______(369) / ______(364)
______(367)
______(370) / ______(365)
______(368)
______(371)
Treatment4 / Treatment5 / Treatment6
Drug’s name
For what problem?
Dose / ______(372)
______(375)
______(378) / ______(373)
______(376)
______(379) / ______(374)
______(377)
______(380)
As an adult has any of the following things happed to you?
If has happened, what was the outcome?
Hospitalization (not for childbirth)YN (381)______(382)
Sexual, physical or emotional abuseYN (383)______(384)
Trauma / loss of consciousnessYN (385)______(386)
Tourette's syndromeYN (387)______(388)
Hyper /Hypothyroidism/
problems with thyroid glandYN (389)______(390)
CarelessincidentsYN (391)______(392)
Convulsions/EpilepsyYN (393)______(394)
Broken bones YN (395)______(396)
Menopause / hormone disbalance YN (397)______(398)
Sensorydeficit like ear lossYN (399)______(400)
Heart diseaseYN (401)______(402)
HighbloodpressureYN (403)______(404)
DiabetesYN (405)______(406)
MigrainesYN (407)______(408)
AsthmaYN (409)______(410)
GlaucomaYN (411)______(412)
During your maturity have you had any of the following diseases?YN (413)
(If you answer yes, please describe them on the lines below.)
______
Psychological / mental history of an adult
As an adult have you ever visited due to any reasons a social worker or psychiatrist?
YN (418)
Expert1 / Expert2 / Expert3For what kind of problem? / (419) / (420) / (421)
Expert’s name / (422) / (423) / (424)
What kind of expert? / (425) / (426) / (427)
At what age did you start? / (428) / (429) / (430)
At what age did you stop? / (431) / (432) / (433)
How often? / (434) / (435) / (436)
Benefits / (437) / (438) / (439)
Reason for cessation / (440) / (441) / (442)
Expert4 / Expert5 / Expert6
For what kind of problem? / (443) / (444) / (445)
Expert’s name / (446) / (447) / (448)
What kind of expert? / (449) / (450) / (451)
At what age did you start? / (452) / (453) / (454)
At what age did you stop? / (455) / (456) / (457)
How often? / (458) / (459) / (460)
Benefits / (461) / (462) / (463)
Reason for cessation / (464) / (465) / (466)
Asanadulthaveyoubeenunderanymentaltreatments?YN (467)
Treatment 1 / Treatment2 / Treatment3Drug’s name / (468) / (469) / (470)
Prescribed by / (471) / (472) / (473)
At what age did you start taking it? / (474) / (475) / (476)
At what age did you stop taking it? / (477) / (478) / (479))
For what problems? / (480) / (481) / (482)
Dose / (483) / (484) / (485)
Benefits / (486) / (487) / (488)
Side effects / (489) / (490) / (491)
Treatment4 / Treatment5 / Treatment6
Drug’s name / (492) / (493) / (494)
Prescribed by / (495) / (496) / (497)
At what age did you start taking it? / (498) / (499) / (500)
At what age did you stop taking it? / (501) / (502) / (503))
For what problems? / (504) / (505) / (506)
Dose / (507) / (508) / (509)
Benefits / (510) / (511) / (512)
Side effects / (513) / (514) / (515)
Questions intending to examine concomitant diseases
As an adult has it happened to you at any stage to
Feel more often depressed or sad or that you can’t be pleased with things that you enjoyed before? Y N (516)
Think about self-injuring,suicide or injuring somebody else?YN (517)
Feel a lot of anxiety or stress or worry the whole time about things
– more than the other people?YN (518)
Have problems with too much or insufficientnutrition?YN (519)
Do you use or have you ever used any of the following substances?
Substance / Use / Ageat
first
use / Age
at
last
use / Age at
the most frequent use / Most frequent use (quantity per day) / Use at the present time
(quantity per day)
Alcoholic drinks / Y N(520) / (521) / (522) / (523) / (524) / (525)
Cigarettes / Y N(526) / (527) / (528) / (529) / (530) / (531)
coffee/tea/coca-cola/soda-water / Y N(532) / (533) / (534) / (535) / (536) / (537)
What illegal substances have you used or use at the moment?
Substance / Ageat
first
use / Age
at
last
use / Age at
the most frequent use / Most frequent
use
(quantity per day) / Use at the present time
(quantity per day)
(538) / (539) / (540) / (541) / (542) / (543)
(544) / (545) / (546) / (547) / (548) / (549)
(550) / (551) / (552) / (553) / (554) / (555)
(556) / (557) / (558) / (559) / (560) / (561)
(562) / (563) / (564) / (565) / (566) / (567)
Have you ever had problems with law?YN (568)
If yes, for what?
______
How many penalty slips for exceeded speed have you had after turning 18 years old?
______
How many car accidents? ______
If you are a future mother, were you smoking during pregnancy? YN (574)
If you are a future mother, were you drinking alcoholic drinks during pregnancy?
YN (574)
Have you ever been involved in legal proceedings?YN (575)
Do your relatives complain that you are irritable or quickly short-tempered?
YN (576)
Do you have fast, sudden changes of temper?YN (577)
Are there significant stresses happening in your life now?YN (578)
If you answer yes to the above question, please describe the stressing factors:
- ______
- ______
- ______
- ______
For more information:
In the USA.....
P.O. Box 950,
North Tonowanda, NY 14120-0950
1-800-456-3003
In Canada...
3770 Victoria Park Ave.,
Toronto, ON M2H 3M6
1-800-268-6011
E-mail:
International/local:+1-416-492-2627
Fax:1-416-424-1736
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