ADHD Informant Report

This form helps Dr Musa Sami’s clinic understand the patient’s difficulties from someone who knows them well.

Patient reference

Please confirm who this report relates to.

If this is not filled automatically, please enter the patient reference shared by the patient. They can find this in emails or messages from Dr Musa Sami’s clinic.

About you

These details help the clinician understand your relationship to the patient.

Your perspective

ADHD symptoms

For each item, please select how often you have observed this and add examples where possible.

Question 1
Often fails to give close attention to details or makes careless mistakes.
Question 2
Often has difficulty sustaining attention in tasks or conversations.
Question 3
Often does not seem to listen when spoken to directly.
Question 4
Often does not follow through on instructions or fails to finish tasks.
Question 5
Often has difficulty organising tasks and activities.
Question 6
Often avoids or dislikes tasks that require sustained mental effort.
Question 7
Often loses things necessary for tasks or activities.
Question 8
Is often easily distracted.
Question 9
Is often forgetful in daily activities.
Question 10
Often fidgets with hands or feet, or squirms when seated.
Question 11
Often leaves seat when remaining seated is expected.
Question 12
Often feels restless or acts as if unable to stay still.
Question 13
Often has difficulty engaging quietly in leisure activities.
Question 14
Is often “on the go” or acts as if driven by a motor.
Question 15
Often talks excessively.
Question 16
Often blurts out answers or finishes other people’s sentences.
Question 17
Often has difficulty waiting their turn.
Question 18
Often interrupts or intrudes on others.

Childhood evidence

Impact on life

Please tell us where you have noticed an impact.

Final details and consent

Submitting your report...