Neurodivergence Questionnaire

Key Points

- This secure form will allow you to provide the information your GP team needs to screen you for ADHD or Autism.
- This includes some questions about key ADHD symptoms, autism symptoms or both.
- Your answers may not be seen immediately meaning this service is not suitable for seeking urgent or emergency care.
- This form should only be used by someone over the age of 13.
- When you are ready to complete your Questionnaire, click the "Answer Screening Questions" tab above.

Neurodivergent Symptoms

- Neurodivergent is not a technical medical term, but rather a non-medical one that desrcribes people who's brains develop or work differently.
- These differences in development or the way the brain works will lead to different strengths and struggles compared to the average person.
- The most common medical conditions referred to with the term "neurodivergent" are ADHD and autism.
- These conditions often present differently in men / boys and women / girls.
- The symptoms of ADHD and Autism are common and can be caused by many other conditions.

ADHD

- ADHD stands for attention deficit hyperactivity disorder.
- This condition presents with issues with attention or increased activity.
- It can also present as a combination of symptoms of poor attention and increased activity.
- There is often an overlap between ADHD and oppositional defiant disorder (ODD)
- For the symptoms to be considered a disorder, there has to be an impact on daily function.

Autism

- Autism is a condition which causes difficulties in interacting with other people.
- These interactions include both communication and behaviors in social settings.
- Generally people with autism struggle to make or keep friends.
- This condition usually affects function at school or work.
- Although often refered to as a spectrum, autism is more a group of socially limiting conditions.

Which screening tests would you like to undertake?

Your Details:

DOB:

I confirm I am over 13 years old and am either the patient or the patient's legal representative (legal guardian or active welfare Power of Attorney).

I agree to my data being processed in line with The Privacy Act 2020.

I confirm I'm registered with Your Practice Name Here.

I confirm I have read the information tab and understand the information within.

These questions relate to your general health.

How often do you drink alcohol?

How much / what do you smoke each day (if anything)?

Are you currently vaping / using a vape?

How would you like to enter your height and weight?

Your BMI is one indicator of a healthy weight.

Your BMI: Please provide your height and weight

Personalised Weight Information

- When you provide a valid height and weight, your BMI will be shown here.
- When you provide a valid height and weight, your ideal weight range will be shown here.
- When you provide a valid height and weight, your recomended change will be shown here.

General Principles

- You can usually lose around 1/2 a kilogram to 1 kilogram a week safely.
- Don't exceed this rate of weight loss unless advised by a doctor or nurse.
- The most effective way to adjust your weight is by modifying your diet.
- If you eat more food (take in more energy), it is likely you will gain weight.
- If you eat less food (take in less energy), it is likely you will lose weight.

Modifying your diet

- It is recommended that you eat three regular meals a day at planned times.
- You should try to avoid snacking unless you're hungry.
- Portion control is the most effective way to adjust your intake.
- Avoid second helpings and leave a rim of 1 inch around your plate.
- Eating 500 calories more a day will cause a gain of around 1/2 a kilogram per week.
- Eating 500 calories less a day will cause a loss of around 1/2 a kilogram per week.

Exercise

- Exercise has a limited role in weight loss, which surprises many people.
- Although it has a limited effect in weight loss, exercise provides many other benefits.
- It is important to stay active for at least 150 minutes / week
- It is generally agreed that you should aim to be active for 30 minutes in a row at least 5 times a week.
- If you are exercising hard enough then you should be too short of breath to sing, but have enough breath to talk.

More information

- More information can be found on your local healthcare website.
- Click on this sentence to be taken to further weight loss (diet focussed) information (in a new tab).
- Click on this sentence to be taken to some general advice on staying healthy.

Please choose either ADHD, autism or both from the "information" tab above to reveal the questions.

These questions are about potential symptoms of ADHD

The questions regarding ADHD symptoms depend on age. They will appear once you enter a date of birth.

These questions are about potential symptoms of ADHD

These questions, known as the ADHD Self Report Scale, help to determine the likleyhood you have ADHD. They should be answered based on what you've experienced in the last 6 months. The ADHD Self Report Scale is produced by the World Health Organisation (WHO).

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

How often do you have difficulty getting things in order when you have to do a task that requires organization?

How often do you have problems remembering appointments or obligations?

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

How often do you feel overly active and compelled to do things, like you were driven by a motor?

How often do you make careless mistakes when you have to work on a boring or difficult project?

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

How often do you misplace or have difficulty finding things at home or at work?

How often are you distracted by activity or noise around you?

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

How often do you feel restless or fidgety?

How often do you have difficulty unwinding and relaxing when you have time to yourself?

How often do you find yourself talking too much when you are in social situations?

When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?

How often do you have difficulty waiting your turn in situations when turn taking is required?

How often do you interrupt others when they are busy?

Did the symptoms of ADHD (that we've asked about above) start before the age of 12?

Do the symptoms of ADHD (that we've asked about above) impact your life?

Do the symptoms of ADHD (that we've asked about above) occur in multiple settings (home / work / social etc)?

You can give further details about your ADHD symptoms at the end of this questionaire if you would like.

These questions are about your child's ADHD symptoms in the past month.

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks.

Often has difficulty sustaining attention in tasks or play activities.

Often does not seem to listen when spoken to directly.

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties.

Often has difficulty organizing tasks and activities.

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

Often loses things necessary for activities (e.g., toys, school assignments, pencils or books).

Often is distracted by extraneous stimuli.

Often is forgetful in daily activities.

Often fidgets with hands or feet or squirms in seat.

Often leaves seat in classroom or in other situations in which remaining seated is expected.

Often runs about or climbs excessively in situations in which it is inappropriate.

Often has difficulty playing or engaging in leisure activities quietly.

Often is “on the go” or often acts as if “driven by a motor”.

Often talks excessively.

Often blurts out answers before questions have been completed.

Often has difficulty awaiting turn.

Often interrupts or intrudes on others (e.g., butts into conversations / games).

Often loses temper.

Often argues with adults.

Often actively defies or refuses adult requests or rules.

Often deliberately does things that annoy other people.

Often blames others for his or her mistakes or misbehaviour.

Often is touchy or easily annoyed by others.

Often is angry and resentful.

Often is spiteful or vindictive.

Do your childs symptoms impact their life or function?

Do your childs symptoms occur in multiple settings (home / school / social etc)?

You can give further details about your child's ADHD Symptoms at the end of this review if you would like.

Please choose either ADHD, autism or both from the "information" tab above to reveal the questions.

These questions are about potential symptoms of Autism

The questions regarding Autism symptoms depend on age. They will appear once you a your date of birth.

These questions are about the Autsim symptoms you've noticed throughout your life.

These questions, known as the Autsism Questionaire 10 (AQ-10), help to determine the likleyhood you have Autism. It is produced by the Autism Research Centre.

I often notice small sounds when others do not.

I usually concentrate more on the whole picture, rather than the small details.

I find it easy to do more than one thing at once.

If there is an interruption, I can switch back to what I was doing very quickly.

I find it easy to 'read between the lines' when someone is talking to me.

I know how to tell if someone listening to me is getting bored.

When I'm reading a story, I find it difficult to work out the characters' intentions.

I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc).

I find it easy to work out what someone is thinking or feeling just by looking at their face.

I find it difficult to work out people’s intentions.

These questions are about the Autsim symptoms you've noticed throughout your child's life.

These questions, known as the Autsism Questionaire 10 (AQ-10), help to determine the likleyhood your child has Autism. It is produced by the Autism Research Centre.

My teenager notices patterns in things all the time.

My teenager usually concentrates more on the whole picture, rather than the small details.

In a social group, my teenager can easily keep track of several different people's conversations.

If there is an interruption, my teenager can switch back to what they were doing very quickly.

My teenager frequently finds that they don't know how to keep a conversation going.

My teenager is good at social chit-chat.

When my teenager was younger, they used to enjoy playing games involving pretending with other children.

My teenager finds it difficult to imagine what it would be like to be someone else.

My teenager finds social situations easy.

My teenager finds it hard to make new friends.

These questions are about the Autsim symptoms you've noticed throughout your child's life.

These questions, known as the Autsism Questionaire 10 (AQ-10), help to determine the likleyhood your child has Autism. It is produced by the Autism Research Centre.

My child often notices small sounds when others do not.

My child usually concentrates more on the whole picture, rather than the small details.

In a social group, my child can easily keep track of several different people's conversations.

My child finds it easy to go back and forth between different activities

My child doesn't know how to keep a conversation going with their peers.

My child is good at social chit-chat.

When my child is read a story, they find it difficult to work out the character's intentions or feelings.

When my child was in preschool, they used to enjoy playing games involving pretending with other children.

My child finds it easy to work out what someone is thinking or feeling just by looking at their face.

My child finds it hard to make new friends.

Are you happy for a clinician to see your responses and complete your review without further discussion (if appropriate)?

Yes, I'm happy without further discussion

No, I would like to discuss my review and I will contact the practice to arrange this