Life Change Associates

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C - PHQ Child ADHD Rating Scale GAD-7 Parents' Rating Scale PHQ PHQ-9 PQRS Revocation of Release of Information SDS Step 1 - Patient Demographics Step 2 - Adult Health History Step 2 - Child/Adolescent Health History Telepsychiatry Post Visit Survey Website Feedback and Suggestions Wender Utah Rating Scale (WURS) Youth Functional Assessment

Wender Utah Rating Scale (WURS)

WURS

Full Name *

Full Name

Date completed

Please read each item carefully and decide which answer fits you best when you were between the age of 6 and 10 years.

Active, restless, always on the go

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Afraid of things

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Start 3-12

Concentration problems, easily distracted

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Anxious, worrying

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Nervous, fidgety

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Inattentive, daydreaming

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Hot- or short-tempered, low boiling point

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Shy, sensitive

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Temper outbursts, tantrums

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Trouble with stick-to-it-iveness, not following through, failing to finish things

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Stubborn, strong willed

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Sad or blue, depressed, unhappy

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

End 3- 12

Incautious, dare-devilish, involved in pranks

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Not getting a kick out of things, dissatisfied with life

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Start 15-17

Disobedient with parents, rebellious, sassy

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Low opinion of myself

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Irritable

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

End 15-17

Outgoing, friendly, enjoyed company of people

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Sloppy, disorganized

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Start 20-21

Moody, ups and downs

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Angry

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

End 20-21

Friends, popular

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Well-organized, tidy, neat

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Start 24-29

Acting without thinking, impulsive *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Tendency to be immature *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Guilty feelings, regretful *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Losing control of myself *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Tendency to be or to act irrational *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Unpopular with other children, didn't keep friends for long, didn't get along with other children *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

End 24-29

Poorly coordinated, did not participate in sports

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Afraid of losing control of self

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Well-coordinated, picked first in games

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Tomboyish (for women only)

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Running away from home

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Getting into fights

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Teasing other children

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Leader, bossy

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Difficulty getting awake

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Follower, led around too much

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Trouble seeing things from someone else's point of view

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Start 41-42

Trouble with authorities, trouble school, visits to principal's office *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Trouble with police, booked, convicted *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

End 41-42

Medical problems as a child:

Headaches

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Stomachaches

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Constipation

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Diarrhea

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Food allergies

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Other allergies

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Bedwetting

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

As a child in school, I was (or had):

Overall a good student, fast

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Overall a poor student, slow learner *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Slow in learning to read

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Slow reader

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Trouble reversing letters

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Problems with spelling

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Trouble with mathematics or numbers *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Bad handwritting

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Able to read pretty well but never really enjoyed reading

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Not achieving up to potential *

0 = Not at all or very slightly

1 = Mildly

2 = Moderately

3 = Quite a bit

4 = Very much

Repeating grades (which grades?)

Suspended or expelled (which grades?)

* Required field