After completing this questionnaire, you'll be able to:
Email to the patient - Click a button to open your email with pre-filled details
Download and send yourself - Download the results file and send it to the patient
Note: The patient will then forward your results to their clinician.
Important Notice:
This questionnaire is for information gathering purposes only and is not diagnostic. The responses you provide will be reviewed by a clinician as part of a comprehensive clinical assessment. Only a qualified healthcare professional can make diagnostic or treatment decisions. Please answer honestly based on your actual observations.
Privacy: All data is processed locally on your device. Nothing is sent anywhere until you choose to download and share your results file with your clinician.
Instructions for Informant: You have been asked to complete this questionnaire about someone close to you. Please rate their behaviour during the past six months.
📝 Answering Questions: You may leave questions blank if you're unsure or they don't apply. Don't guess - skipped items will be excluded from score calculations. However, try to answer as many as you can for accurate results.
0 of 28 items answered (28 skipped) (0%)
Information
Current Behaviour (Past 6 Months)
Rate the patient's behaviour during the past six months
0 = Never/rarely1 = Sometimes2 = Often3 = Very often (several times per hour/day)
Impact on Daily Life
To what extent do these behaviours interfere with the patient's ability to function in each area?
0 = Never/rarely1 = Sometimes2 = Often3 = Very often (several times per hour/day)
✓ Questionnaire Complete
Thank you for completing this questionnaire
Your responses have been saved. Please send your results to the patient using one of the options below.
Your clinician will review these results and schedule the next step (a structured clinical interview) before any diagnostic conclusions can be reached.
Send Results to Patient:
Your results file is downloading now. Once it appears in your Downloads folder, attach it to the email that just opened and send.
Option 1: Click "Email Results" to open your email app with instructions. Attach the file and send to the patient. Option 2: Download the file and send it to the patient yourself.
The patient will then forward your responses to their clinician (Dr. Shah at draanashah@protonmail.com).