CURRENT BEHAVIOUR SCALE – COLLATERAL REPORT

PRIVATE & CONFIDENTIAL
Source: UKAAN (www.ukaan.org)

Completed by a PARTNER/SPOUSE/DEFACTO or other nominated collateral of a patient - Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

Your Details (Collateral Person)

Your First Name *

Your Surname *

Relationship to the Patient *

Other (Relationship) *

Estimate duration of relationship *

Patient Details

Patient's First Name *

Patient's Last Name *

Date of Birth *

PARTNER REPORT

Please select the most appropriate option that best describes your partner's behaviour
DURING THE PAST 6 MONTHS

0 = Never or Rarely: This is not a problem or concern. Any challenges are age-appropriate

1 = Sometimes: Some difficulty (somewhat)

2 = Often: This is a problem (pretty much)

3 = Very Often: This is a serious problem (very much)

Fails to give close attention to details or make careless mistakes in work *

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Fidgets with hands or feet or squirms in seat *

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Has difficulty sustaining attention in tasks or fun activities *

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Leaves seat in situations in which sitting is expected *

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Appears not to listen when spoken to directly *

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Appears restless *

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Does not follow through on instructions and fails to finish work *

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Has difficulty engaging in leisure activities or doing fun things quietly *

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Has difficulty organising tasks and activities *

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Appears to be “on the go all the time ” or as if “driven by a motor” *

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Avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort *

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Talk excessively *

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Loses things necessary for tasks or activities *

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Blurts out answers before questions have been completed *

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Easily distracted *

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Has difficulty awaiting turn *

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Forgetful in daily activities *

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Interrupts or intrude on others *

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Behaviour

To what extent do the problems you may have indicated interfere with your
partner’s ability to function in each of these areas of life activities?

In his/her home life with immediate family *

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In his/her work or occupation *

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In his/her social interactions with others *

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In his/her activities or dealings in the community *

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In any educational activities *

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In your dating or marital relationship *

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In his/her management of money *

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In his/her ability to drive a motor vehicle *

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In his/her leisure or recreational activities *

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In his/her management of daily responsibilities *

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Areas

SIGNATURE

I confirm the information I have provided is true, complete and accurate. *

Partner Signature *

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Today's Date *

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