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Please fill out this questionnaire to provide some background information about you and the issues you have been experiencing. If you need extra time, you can always save the answers and revist them later.

Your email

Your Age

Gender

Male

Female

Non-binary

Transgender

I prefer not to say

Country

Pre-Existing Conditions

Do you have any of the following? This can be either diagnosis or self-diagnosed. Choose as many as option as you like, or none if not applicable.

Anxiety Disorder

Autism

Bipolar Disorder

Borderline Personality Disorder

Dyslexia

Dyspraxia

ADHD/ ADD

Dyscalculia

Dysgraphia

Insomnia

Obsessive Compulsive Disorder (OCD)

Post Traumatic Stress Disorder (PTSD)

Schizophrenia

Substance Use Disorder

Your social behaviour

When you’re having a conversation with someone, do you prefer to look:

At the wall

Their shoes

Their mouth

Anywhere but directly into their eyes

Somewhere else

Think about your daily routine

Would you say you follow the same schedule every day of the week, and don’t like unexpected events?

Very Often

Often

Sometimes

Rarely

Never

Feeling embarrassed

Do you have trouble understanding what people mean when they say they feel embarrassed for someone else?

Very Often

Often

Sometimes

Rarely

Never

Do you often fail to give close attention to details?

Do you make careless mistakes in your work or during other activities? And how was that during childhood (in schoolwork or during other activities)?

Examples adulthood

Makes careless mistakes

Works slowly to avoid mistakes

Work is inaccurate

Overlooks or misses details

Does not read instructions carefully

Too much time needed to complete detailed tasks

Gets easily bogged down by details

Works too quickly and therefore makes mistakes

Other:

Examples childhood

Careless mistakes in schoolwork

Mistakes made by not reading questions properly

Overlooks or misses details

Work is inaccurate

Leaves questions unanswered by not reading them properly

Leaves the reverse side of a test unanswered

Others comment about careless work

Not checking the answers in homework

Too much time needed to complete detailed tasks

Other:

Do you often have difficulty sustaining your attention in tasks?

Examples adulthood

Not able to keep attention on tasks for long

Quickly distracted by own thoughts or associations

Easily distracted by unrelated thoughts

Difficulty remaining focused during lectures and/or conversations

Finds it difficult to watch a film through to the end, or to read a book

Quickly becomes bored with things

Asks questions about subjects that have already been discussed

Other:

Examples childhood

Difficulty keeping attention on schoolwork

Difficulty keeping attention on play

Difficulty remaining focused during lectures and/or conversations

Easily distracted

Difficulty concentrating

Needing structure to avoid becoming distracted

Quickly becoming bored of activities

Other:

Does it often seem as though you are not listening when you are spoken to directly?

Examples adulthood

Dreamy or preoccupied

Difficulty concentrating on a conversation

Afterwards, not knowing what a conversation was about

Often changing the subject of the conversation

Others saying that your thoughts are somewhere else

Mind seems elsewhere, even in the absence of any obvious distraction

Other:

Examples childhood

Not knowing what parents/teachers have said

Dreamy or preoccupied

Only listening during eye contact or when a voice is raised

Mind seems elsewhere, even in the absence of any obvious distraction

Often having to be addressed again

Questions having to be repeated

Other:

Do you often not follow through on instructions?

Or often fail to finish chores or duties in the workplace? And how was that during childhood (in schoolwork)?

Examples adulthood

Does things that are muddled up together without completing them

Starts tasks but quickly loses focus and is easily side tracked

Needing a time limit to complete tasks

Difficulty completing administrative tasks

Difficultly following instructions from a manual

Other:

Examples childhood

Difficulty following instructions

Difficulty with instructions involving more than one step

Starts tasks but quickly loses focus and is easily side tracked

Not completing things

Not completing homework or handing it in

Needing a lot of structure in order to complete tasks

Other:

Do you often find it difficult to organise tasks and activities?

Examples adulthood

Difficultly with planning activities of daily life

Difficulty managing sequential tasks

House and/or workplace are disorganised

Difficulty keeping materials and belongings in order

Works messy and disorganized

Planning too many tasks or non-efficient planning

Regularly booking things to take place at the same time (double-booking)

Arriving late

Fails to meet deadlines

Not able to use an agenda or diary consistently

Inflexible because of the need to keep to schedules

Poor sense and management of time

Creating schedules but not using them

Needing other people to structure things

Other:

Examples Childhood

Difficultly being ready on time

Messy room / desk and/or work

Difficulty keeping materials and belongings in order

Difficultly playing alone

Difficulty planning tasks or homework

Fails to meet deadlines

Doing things in a muddled way

Arriving late

Poor sense of time

Difficulty keeping himself/herself entertained

Other:

Do you often avoid tasks that require sustained mental effort?

Examples adulthood

Do the easiest or nicest things first of all

Often postpone boring or difficult tasks

Postpone tasks so that deadlines are missed

Avoid monotonous work, such as administration

Avoids preparing reports, completing forms, or reviewing lengthy papers

Do not like reading due to mental effort

Avoidance of tasks that require a lot of concentration

Other:

Examples childhood

Avoidance of homework or has an aversion to this

Reads few books or does not feel like reading due to mental effort

Avoidance of tasks that require a lot of concentration

Aversion to school subjects that require a lot of concentration

Often postpones boring or difficult tasks.

Other:

Do you often lose things that are necessary for tasks or activities?

Examples adulthood

Mislays tools, paperwork, eyeglasses, mobile telephones, wallet, keys, or agenda

Often leaves things behind

Loses papers for work

Loses a lot of time searching for things

Gets in a panic if other people move things around

Stores things away in the wrong place

Loses notes, lists or telephone numbers

Other:

Examples childhood

Loses school materials, pencils, books, or other items

Mislays toys, clothing, or homework

Spends a lot of time searching for things

Gets in a panic if other people move things around

Comments from parents and/or teacher about things being lost

Other:

Are you often easily distracted by extraneous stimuli?

Examples adulthood

Difficulty shutting off from external stimuli

After being distracted, difficult to pick up the thread again

Easily distracted by noises or events

Easily distracted by the conversations of others

Difficulty in filtering and/or selecting information

Other:

Examples childhood

In the classroom, often looking outside

Easily distracted by noises or events

After being distracted, has difficultly picking up the thread again

Other:

Are you often forgetful in daily activities?

Examples adulthood

Forgets appointments or other obligations

Forgets keys, agenda etc.

Needs frequent reminders for appointments

Forgets to pay bills or to return calls

Returning home to fetch forgotten things

Rigid use of lists to make sure things aren’t forgotten

Forgets to keep or look at daily agenda

Forgets to do chores or run errands

Other:

Examples childhood

Forgets appointments or instructions

Forgets to do chores or run errands

Has to be frequently reminded of things

Half-way through a task, forgetting what has to be done

Forgets to take things to school

Leaving things behind at school or at friends’ houses

Other:

Do you often fidget with or tap hands or feet, or squirm in your seat?

Examples adulthood

Difficulty sitting still

Fidgets with the legs

Tapping with a pen or playing with something

Fiddling with hair or biting nails

Able to control restlessness, but feels stressed as a result

Other:

Examples childhood

Parents often said “sit still” or similar

Fidgets with the legs

Tapping with a pen or playing with something

Fiddling with hair or biting nails

Unable to remain seated in a chair in a relaxed manner

Able to control restlessness, but feels stressed as a result

Other:

Do you often leave your seat in situations where it is expected that you remain seated?

Examples adulthood

Often leaves his/her place in the office or in the workplace

Avoids symposiums, lectures, church etc.

Prefers to walk around rather than sit

Never sits still for long, always moving around

Stressed owing to the difficulty of sitting still

Makes excuses in order to be able to walk around

Other:

Examples childhood

Often stands up while eating or leaves his/her place in the classroom

Finds it very difficult to stay seated at school or during meals

Being told to remain seated

Making excuses in order to walk around

Other:

Do you often feel restless?

Examples adulthood

Feeling restless or agitated inside

Constantly having the feeling that you have to be doing something

Finding it hard to relax

Other:

Examples childhood

Always running around where it is inappropriate

Climbing on furniture, or jumping on the sofa

Climbing in trees

Feeling restless inside

Other:

Do you often find it difficult to engage in leisure activities quietly?

Examples adulthood

Talks during activities when this is not appropriate

Becoming quickly too cocky in public

Being loud in all kinds of situations

Difficulty doing activities quietly

Difficultly in speaking softly

Other:

Examples childhood

Being loud-spoken during play or in the classroom

Unable to watch TV or films quietly

Asked to be quieter or calm down

Becoming quickly too cocky in public

Other:

Are you often “on the go” or do you often act as if “driven by a motor”?

Examples adulthood

Always busy doing something

Is uncomfortable being still for extended time, e.g. in restaurants or meetings

Has too much energy, always on the move

Others find you restless or difficult to keep up with

Stepping over own boundaries

Finds it difficult to let things go, excessively driven

Other:

Examples childhood

Constantly busy

Others find you restless or difficult to keep up with

Is uncomfortable being still for extended time

Excessively active at school and at home

Has lots of energy

Always on the go, excessively driven

Other:

Do you often talk excessively?

Examples adulthood

So busy talking that other people find it tiring

Known to be an incessant talker

Finds it difficult to stop talking

Tendency to talk too much

Not giving others room to interject during a conversation

Needing a lot of words to say something

Other:

Examples childhood

Known as a chatterbox

Teachers and parents often ask you to be quiet

Comments in school reports about talking too much

Being punished for talking too much

Keeping others from doing schoolwork by talking too much

Not giving others room during a conversation

Other:

Do you often blurt out an answer before questions have been completed?

.. and how was that during childhood?

Examples adulthood

Being a blabbermouth, saying what you think

Saying things without thinking first

Giving people answers before they have finished speaking

Completing other people’s sentences

Being tactless

Other:

Examples childhood

Being a blabbermouth, saying things without thinking first

Wants to be the first to answer questions at school

Blurts out an answer even if it is wrong

Interrupts others before sentences are finished

Difficulty waiting for turn during conversations

Coming across as being tactless

Other:

Do you often find it difficult to await your turn?

.. and how was that during childhood?

Examples adulthood

Difficulty waiting in a queue, jumping the queue

Difficulty in patiently waiting in the traffic/traffic jams

Being impatient

Quickly starting relationships/jobs, or ending/leaving these because of impatience

Other:

Examples childhood

Difficultly waiting turn in group activities

Difficultly waiting turn in the classroom

Always being the first to talk or act

Becomes quickly impatient

Crosses the road without looking

Other:

Do you often interrupt or intrude on others?

.. and how was that during childhood?

Examples adulthood

Being quick to interfere with others

Intrudes on others

Disturbs other people’s activities without being asked, or takes over their tasks

Comments from others about interference

Difficulty respecting the boundaries of others

Having an opinion about everything and immediately expressing this

Other:

Examples childhood

Interrupts the games or activities of others

Starts using people’s things without asking or permission

Interrupts the conversations of others

Reacts to everything

Unable to wait

Other:

In which areas do you have or had problems with these symptoms?

Examples adulthood: Work/education

Did not complete education/training needed for work

Work below level of education

Tire quickly of a workplace

Pattern of many short-lasting jobs

Difficulty with administrative work/planning

Not achieving promotions

Under-performing at work

Left work following arguments or dismissal

Sickness benefits/disability benefit as a result of symptoms

Limited impairment through compensation of high IQ

Limited impairment through compensation of external structure

Examples childhood: Education

Lower educational level than expected based on IQ

Staying back (repeating classes) as a result of concentration problems

Education not completed / rejected from school

Took much longer to complete education than usual

Achieved education suited to IQ with a lot of effort

Difficulty doing homework

Followed special education on account of symptoms

Comments from teachers about behaviour or concentration

Limited impairment through compensation of high IQ

Limited impairment through compensation of external structure

In which areas do you have or had problems with these symptoms?

Examples adulthood: Relationship and/or family

Tire quickly of relationships

Impulsively commencing or ending relationships

Unequal partner relationship owing to symptoms

Relationship problems, lots of arguments, lack of intimacy

Divorced owing to symptoms

Problems with sexuality as a result of symptoms

Problems with upbringing as a result of symptoms

Difficulty with housekeeping or or administration

Financial problems or gambling

Not daring to start a relationship

Other:

Examples childhood: Family

Frequent arguments with brothers or sisters

Frequent punishment or hiding

Little contact with family on account of conflicts

Required structure from parents for a longer period than would normally be the case

Other:

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