David Nolte Pharmacy
Behavioural Traits Questionnaire

Please fill out the following questionnaire relating to your behavioural traits. Please complete ALL questions – as the more questions you answer the more accurate the results.
The questionnaire should take less than 10 minutes to answer, but please take your time and accurately complete the questionnaire.

Once the questionnaire is completed click the “submit” button at the bottom of the final page. If you exit the program before clicking the “submit” button no answers will be recorded or results presented. Also refrain from using the web-browser's "Back" button; if you require to return to previous questions please use the “previous” button at the bottom of the page. Use of the web-browser's "refresh" button will also clear any answers you have already entered.

Information collected through this form is for the sole use of David Nolte in relation to the individual concerned and holds only such personal information as is reasonable for us to deliver services to our patients. All information received will be kept confidential in accordance with the Privacy Act 1988 of the Commonwealth of Australia.

Agree, and Begin Questionnaire           No thanks

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First name:       Last name:
Email:            Tick for permission to contact you via email
Sex:   Male   Female
Age:
Current Medication (Prescription, Over-the-counter & Herbal):
Medical Conditions:

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Personal G.P. Details:
Name of G.P.:
Phone of G.P.:       Address of G.P.:
                       Tick for permission for a David Nolte Pharmacist to contact your G.P. to discuss questionnaire results.  

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Please rate yourself (or the person you are evaluating) on each of the symptoms listed below.
Use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
    NA = Not Applicable

Q #	Situation	Appropriate score
a.01	Is easily distracted	0	1	2	3	4	NA
a.02	Has difficulty sustaining attention span for most tasks in play, school or work.	0	1	2	3	4	NA
a.03	Has trouble listening when others are talking.	0	1	2	3	4	NA
a.04	Has trouble following through on tasks or instructions.	0	1	2	3	4	NA
a.05	Has difficulty keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.)	0	1	2	3	4	NA
a.06	Has trouble with time, for example, is frequently late or hurried, tasks take longer than expected, projects or homework are “last minute” or turned in late.	0	1	2	3	4	NA
a.07	Has a tendency to lose things.	0	1	2	3	4	NA
a.08	Makes careless mistakes, poor attention to detail.	0	1	2	3	4	NA
a.09	Is forgetful.	0	1	2	3	4	NA
a.10	Daydreams excessively.	0	1	2	3	4	NA
a.11	Complains of being bored.	0	1	2	3	4	NA
a.12	Appears apathetic or unmotivated.	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
a.13	Is tired, sluggish or slow moving.	0	1	2	3	4	NA
a.14	Is spacey or seems preoccupied.	0	1	2	3	4	NA
a.15	Is restless of hyperactive.	0	1	2	3	4	NA
a.16	Has trouble sitting still.	0	1	2	3	4	NA
a.17	Is fidgety; in constant motion (hands, feet, body)	0	1	2	3	4	NA
a.18	Is noisy; has a hard time being quiet.	0	1	2	3	4	NA
a.19	Acts if “driven by a motor”	0	1	2	3	4	NA
a.20	Talks excessively.	0	1	2	3	4	NA
a.21	Is impulsive (doesn’t think through comments or actions before they are said or done)	0	1	2	3	4	NA
a.22	Has difficulty waiting his or her turn.	0	1	2	3	4	NA
a.23	Interrupts or intrudes on others (e.g. butts into conversations or games)	0	1	2	3	4	NA
a.24	Worries excessively or senselessly.	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
a.25	Is super organized.	0	1	2	3	4	NA
a.26	Is oppositional, argumentative.	0	1	2	3	4	NA
a.27	Has a strong tendency to get locked into negative thoughts; has the same thought over and over.	0	1	2	3	4	NA
a.28	Has a tendency towards compulsive behavior.	0	1	2	3	4	NA
a.29	Has an intense dislike of change.	0	1	2	3	4	NA
a.30	Has a tendency to hold grudges.	0	1	2	3	4	NA
a.31	Has trouble shifting attention from subject to subject.	0	1	2	3	4	NA
a.32	Has difficulties seeing options in situations.	0	1	2	3	4	NA
a.33	Has a tendency to hold on to own opinion and not listen to others.	0	1	2	3	4	NA
a.34	Has a tendency to get locked into a course of action, whether or not it is good for the person.	0	1	2	3	4	NA
a.35	Needs to have things done a certain way or becomes very upset.	0	1	2	3	4	NA
a.36	Others complain that he/she worries too much.	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
a.37	Has periods of quick temper or rages with little provocation.	0	1	2	3	4	NA
a.38	Misinterprets comments as negative when they are not.	0	1	2	3	4	NA
a.39	Irritability tends to build, then explodes, then recedes; is often tired after a rage.	0	1	2	3	4	NA
a.40	Has periods of spaciness or confusion.	0	1	2	3	4	NA
a.41	Has periods of panic and/or fear for no specific reason.	0	1	2	3	4	NA
a.42	Perceives visual changes, such as seeing shadows or objects changing shape.	0	1	2	3	4	NA
a.43	Has frequent periods of déjà vu (feeling of being somewhere before even though he or she has never been there)	0	1	2	3	4	NA
a.44	Is sensitive or mildly paranoid.	0	1	2	3	4	NA
a.45	Has headaches or abdominal pain of unknown origin.	0	1	2	3	4	NA
a.46	Has a history of a head injury or a family history of violence or explosiveness.	0	1	2	3	4	NA
a.47	Has dark thoughts, may involve suicidal or homicidal thoughts.	0	1	2	3	4	NA
a.48	Has periods of forgetfulness or memory problems.	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
a.49	Has a short fuse or periods of extreme irritability.	0	1	2	3	4	NA
a.50	Is moody.	0	1	2	3	4	NA
a.51	Is negative.	0	1	2	3	4	NA
a.52	Has low energy.	0	1	2	3	4	NA
a.53	Is frequently irritable.	0	1	2	3	4	NA
a.54	Has a tendency to be socially isolated.	0	1	2	3	4	NA
a.55	Has frequent feelings of hopelessness.	0	1	2	3	4	NA
a.56	Has lowered interest in things that are usually considered fun.	0	1	2	3	4	NA
a.57	Undergoes sleep changes (too much or too little)	0	1	2	3	4	NA
a.58	Has chronic low self-esteem.	0	1	2	3	4	NA
a.59	In angry or aggressive.	0	1	2	3	4	NA
a.60	Is sensitive to noise, light, clothes or touch.	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
a.61	Undergoes frequent or cyclical mood changes.	0	1	2	3	4	NA
a.62	Is inflexible, rigid in thinking.	0	1	2	3	4	NA
a.63	Demands to have his or her way, even when told “no” multiple times.	0	1	2	3	4	NA
a.64	Has periods of mean, nasty, or insensitive behavior.	0	1	2	3	4	NA
a.65	Has periods of increased talkativeness.	0	1	2	3	4	NA
a.66	Has periods of increased impulsivity.	0	1	2	3	4	NA
a.67	Displays unpredictable behavior.	0	1	2	3	4	NA
a.68	Way of thinking is grandiose or “larger than life”	0	1	2	3	4	NA
a.69	Talks fast.	0	1	2	3	4	NA
a.70	Feels that thought go fast.	0	1	2	3	4	NA
a.71	Appears anxious or fearful.	0	1	2	3	4	NA

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Please rate yourself (or the person you are evaluating) on each of the behaviour listed below.
Use the following scale to choose the most appropriate number for each behaviour.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
b.01	Feelings of nervousness or anxiety	0	1	2	3	4	NA
b.02	Panic attacks	0	1	2	3	4	NA
b.03	Symptoms of heightened muscle tension (headaches, sore muscles, etc.)	0	1	2	3	4	NA
b.04	Periods of heart pounding, rapid heart rate, or chest pain	0	1	2	3	4	NA
b.05	Periods of trouble breathing, or feeling smothered	0	1	2	3	4	NA
b.06	Periods of feeling dizzy, faint, or unsteady on your feet	0	1	2	3	4	NA
b.07	Periods of nausea or abdominal upset	0	1	2	3	4	NA
b.08	Periods of sweating, hot or cold flashes, cold hands	0	1	2	3	4	NA
b.09	Tendency to predict the worst	0	1	2	3	4	NA
b.10	Fear of dying or doing something crazy	0	1	2	3	4	NA
b.11	Avoidance of public places for fear of having an anxiety attack	0	1	2	3	4	NA
b.12	Conflict avoidance	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
b.13	Excessive fear of being judged or scrutinized by others	0	1	2	3	4	NA
b.14	Persistent phobias	0	1	2	3	4	NA
b.15	Low motivation	0	1	2	3	4	NA
b.16	Excessive motivation	0	1	2	3	4	NA
b.17	Tics	0	1	2	3	4	NA
b.18	Poor Handwriting	0	1	2	3	4	NA
b.19	Quick startle reaction	0	1	2	3	4	NA
b.20	Tendency to freeze in anxiety-provoking situations	0	1	2	3	4	NA
b.21	Excessive worry about what others think	0	1	2	3	4	NA
b.22	Shyness or timidity	0	1	2	3	4	NA
b.23	Low threshold of embarrassment	0	1	2	3	4	NA

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Please rate yourself (or the person you are evaluating) on each of the behaviour listed below.
Use the following scale to choose the most appropriate number for each behaviour.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
c.01	Feelings of sadness	0	1	2	3	4	NA
c.02	Moodiness	0	1	2	3	4	NA
c.03	Negativity	0	1	2	3	4	NA
c.04	Low Energy	0	1	2	3	4	NA
c.05	Irritability	0	1	2	3	4	NA
c.06	Decreased interest in others	0	1	2	3	4	NA
c.07	Feelings of hopelessness about future	0	1	2	3	4	NA
c.08	Feelings of helplessness or powerlessness	0	1	2	3	4	NA
c.09	Feeling dissatisfied or bored	0	1	2	3	4	NA
c.10	Excessive guild	0	1	2	3	4	NA

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Continue to use the following scale to choose the most appropriate number for each situation.
     0 = Never
     1 = Rarely
     2 = Occasionally
     3 = Frequently
     4 = Very Frequently
     NA = Not Applicable

Q #	Situation	Appropriate score
c.11	Suicidal feelings	0	1	2	3	4	NA
c.12	Crying	0	1	2	3	4	NA
c.13	Lowered interest in things usually considered fun	0	1	2	3	4	NA
c.14	Sleep changes (too much or too little)	0	1	2	3	4	NA
c.15	Appetite changes (too much or too little)	0	1	2	3	4	NA
c.16	Low self-esteem	0	1	2	3	4	NA
c.17	Decreased interest in sex	0	1	2	3	4	NA
c.18	Negative sensitivity to smells / odors	0	1	2	3	4	NA
c.19	Forgetfulness	0	1	2	3	4	NA
c.20	Poor concentration	0	1	2	3	4	NA

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