ADHD Assessment – New Eltham & Blackfen Medical Centre AQ50 Form Please complete your personal details below:Name First Last Email Enter Email Confirm Email Phone NumberNHS number (if known) OptionalAddress Street Address Address Line 2 City Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands For each statement below, choose one response that best describes how strongly that statement applies to you:1. I prefer to do things with others, rather than on my own. Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 2. I prefer to do things the same way over and over again Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 3. If I try to imagine something, I find it very easy to create a picture in my mind Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 4. I frequently get so strongly absorbed in one thing that I lose sight of other things Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 5. I often notice small sounds when others do not Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 6. I usually notice car number plates or similar strings of information Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 7. Other people frequently tell me that what I’ve said is impolite, even though I think it is polite Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 8. When I’m reading a story, I can easily imagine what the characters might look like Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 9. I am fascinated by dates Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 10. In a social group, I can easily keep track of several different people’s conversations Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 11. I find social situations easy Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 12. I tend to notice details that others do not Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 13. I would rather go to a library than to a party Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 14. I find making up stories easy Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 15. I find myself drawn more strongly to people than to things Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 16. I tend to have very strong interests, which I get upset about if I can’t pursue Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 17. I enjoy social chitchat Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 18. When I talk, it isn’t always easy for others to get a word in edgewise Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 19. I am fascinated by numbers Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 20. When I’m reading a story, I find it difficult to work out the characters’ intentions Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 21. I don’t particularly enjoy reading fiction Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 22. I find it hard to make new friends Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 23. I notice patterns in things all the time Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 24. I would rather go to the theatre than to a museum Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 25. It does not upset me if my daily routine is disturbed Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 26. I frequently find that I don’t know how to keep a conversation going Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 27. I find it easy to ‘read between the lines’ when someone is talking to me Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 28. I usually concentrate more on the whole picture, rather than on the small details Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 29. I am not very good at remembering phone numbers Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 30. I don’t usually notice small changes in a situation or a person’s appearance Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 31. I don’t know how to tell if someone listening to me is getting bored Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 32. I find it easy to do more than one thing at once Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 33. When I talk on the phone, I’m not sure when it’s my turn to speak Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 34. I enjoy doing things spontaneously Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 35. I am often the last to understand the point of a joke Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 36. I find it easy to work out what someone is thinking or feeling just by looking at their face Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 37. If there is an interruption, I can switch back to what I was doing very quickly Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 38. I am good at social chitchat Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 39. People often tell me that I keep going on and on about the same thing Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 40. When I was young, I used to enjoy playing games involving pretending with other children Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 41. I like to collect information about categories of things (e.g. types of cars, birds, trains, plants) Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 42. I find it difficult to imagine what it would be like to be someone else Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 43. I like to carefully plan any activities I participate in Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 44. I enjoy social occasions Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 45. I find it difficult to work out people’s intentions Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 46. New situations make me anxious Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 47. I enjoy meeting new people Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 48. I am a good diplomat Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 49. I am not very good at remembering people’s date of birth Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree 50. I find it very easy to play games with children that involve pretending Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree Comments OptionalPlease let us know what's on your mind. Have a question for us? Ask away.