ACE-SR: ACE Self-Report Rating Scale

ACE-SR is a rating scale that will ask you to provide information about your behaviour
over the last six months.

Date of Completion: _____________________________

Name: _____________________________

Date of Birth: _____________________________

Please complete the following questions by circling one answer only (never, rarely,
sometimes, often or don’t know) relating to your functioning or behaviour over the
last six months.

Next, with reference to the rating you have provided (never, rarely, sometimes or
often), please provide (a) specific examples of the behaviour, (b) how it impacts on
your personal, social, educational and/or occupational activities, and (c) whether
adjustments have to be made to manage or prevent any problems that arise.

Please provide as much information as possible, using a separate page if necessary.

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P1: Over the last 6 MONTHS, have you failed to give close attention to details or made Never Rarely Sometimes Often
careless mistakes (e.g. difficulty concentrating on boring or repetitive tasks)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P2: Over the last 6 MONTHS, have you failed to sustain attention in tasks or activities Never Rarely Sometimes Often
(e.g. maintaining your focus over a long period when concentrating on tasks)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P3: Over the last 6 MONTHS, did you not listen to what was being said to you (e.g. Never Rarely Sometimes Often
difficulty concentrating on what people say, even when speaking to you directly)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P4: Over the last 6 MONTHS, have you failed to follow through on instructions or finish Never Rarely Sometimes Often
tasks (e.g. not completing work, taking ‘short-cuts’ and missing things out)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

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P5: Over the last 6 MONTHS, have you struggled to organise tasks and activities (e.g. Never Rarely Sometimes Often
difficulty structuring and planning tasks on your own, missing deadlines)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P6: Over the last 6 MONTHS, did you avoid or strongly dislike tasks requiring sustained Never Rarely Sometimes Often
mental effort (e.g. by delaying or reluctantly starting tasks that take a lot of thought)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P7: Over the last 6 MONTHS, have you lost things necessary for certain tasks or activities Never Rarely Sometimes Often
(e.g. misplaced or had difficulty finding things you need at home or school)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P8: Over the last 6 MONTHS, have you been easily distracted by things going on around Never Rarely Sometimes Often
you (e.g. by noise or activities going on around you in the environment)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

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P9: Over the last 6 MONTHS, have you been forgetful in your daily activities (e.g. Never Rarely Sometimes Often
forgetting items you needed for activities, or things you must do)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P10: Over the last 6 MONTHS, did you fidget with your hands or feet or squirm about Never Rarely Sometimes Often
when sitting down (e.g. can’t sit still, wriggling in your chair, fiddling with items)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P11: Over the last 6 MONTHS, have you left your seat in situations you are expected to Never Rarely Sometimes Often
remain seated (e.g. in class at school, places of worship, on public transport)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P12: Over the last 6 MONTHS, have you been hyperactive (e.g. overly active, running Never Rarely Sometimes Often
about or climbing things without thinking about others or your own safety)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

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P13: Over the last 6 MONTHS, have you been very noisy and/or struggled to get on with Never Rarely Sometimes Often
activities quietly (e.g. can’t settle or play quietly, talked or shouted during quiet time)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P14: Over the last 6 MONTHS, have you been persistently active and ‘on the go’ (e.g. Never Rarely Sometimes Often
always rushing around, like a whirlwind, can’t switch off)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P15: Over the last 6 MONTHS, have you interrupted others when they were speaking Never Rarely Sometimes Often
(e.g. impatiently blurting out thoughts or answers, not waiting your turn to speak)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P16: Over the last 6 MONTHS, have you had difficulty waiting your turn when turn-taking Never Rarely Sometimes Often
was expected (e.g. waiting in line, waiting for your turn in sports or games)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

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P17: Over the last 6 MONTHS, have you interrupted or intruded on others (e.g. on Never Rarely Sometimes Often
conversations, private space or activities of others)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

P18: Over the last 6 MONTHS, have you talked excessively even when this was Never Rarely Sometimes Often
inappropriate (e.g. persistent chattering, without constraint, dominating conversation)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.

Thank you for completing ACE-SR - please check you have completed the rating for each
item (never, rarely, sometimes, often or don’t know).

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