Young DIVA-5 Diagnostic Interview Workspace

Patient Demographics

Patient Name

Date of Birth

Sex

Interview Date

Clinician's Name

Patient ID / Number

Part 1: Symptoms of Attention Deficit (Criterion A1 of the DSM-5)

Instructions: Current symptoms must have been present for at least 6 months, showing a chronic, non-episodic course.

A1. Careless mistakes / fails to pay attention to details

Present

A2. Difficulty maintaining attention on tasks or play activities

Present

A3. Seems like they are not listening when spoken to directly

Present

A4. Does not follow instructions / fails to complete schoolwork or assignments

Present

A5. Difficulty organizing tasks and activities

Present

A6. Avoids, dislikes, or hesitates tasks requiring sustained mental effort (e.g., homework)

Present

A7. Loses things necessary for tasks or activities

Present

A8. Easily distracted by strange or extraneous stimuli

Present

A9. Forgetful in daily activities

Present

Part 2: Symptoms of Hyperactivity-Impulsivity (Criterion A2 of the DSM-5)

Instructions: Current symptoms must have been present for at least 6 months, showing a chronic, non-episodic course.

H/I 1. Fidgets with or taps hands/feet, or twists in chair

Present

H/I 2. Leaves seat in situations where remaining seated is expected

Present

H/I 3. Feels restless or runs/climbs in situations where it is inappropriate

Present

H/I 4. Difficulty engaging in leisure or play activities in silence

Present

H/I 5. Always 'on the go', acting as if driven by an internal motor

Present

H/I 6. Talks excessively

Present

H/I 7. Blurts out answers before questions have been completed

Present

H/I 8. Difficulty waiting for their turn

Present

H/I 9. Interrupts or interferes with others

Present

Part 3: Damage Due to Symptoms (Criteria B, C, and D of the DSM-5)

Criterion B: Have they always had these symptoms of attention deficit and/or hyperactivity-impulsivity?

Criterion C and D: In which settings have they had structural problems with these symptoms? (Select all that apply)

Home / Family life School / College / Education Social contacts / Peers

Free time / Hobbies Self-confidence / Self-image

Page 14 Summary Table & Page 17 Scoring Form

Manual Page 14 Verification Tracker (Automatically Aggregating):

ADHD Clinical Domain	Total Present Symptoms Verified	Diagnostic Cut-off Threshold
Attention Deficit (A1)	0 / 9	Requires at least 6 symptoms
Hyperactivity-Impulsivity (A2)	0 / 9	Requires at least 6 symptoms

Page 17 Diagnostic Score Matrix Form

DSM-5 Criterion A (Age less than 17 years) At least 6 symptoms of inattention and/or 6 symptoms of hyperactivity-impulsivity for at least 6 months?
DSM-5 Criterion B Several symptoms (at least 3) were present before the age of 12?
DSM-5 Criterion C & D The symptoms and deficiencies are expressed across at least two domains of operation?
DSM-5 Criterion E The symptoms cannot be better explained by the presence of another psychiatric disorder?

Collateral Informant Integration (0 = None/Little, 1 = Some, 2 = Clear Support)

Father(s) / Mother / Brother / Sister / Other Informant	N/D 0 1 2
Partner / Good Friend / Other Informant	N/D 0 1 2
School Reports / Teacher Scales	N/A 0 1 2

Diagnosis Outcome Selection Partially in remission

Gravity / Clinical Severity

Valant Progress Note Ready Report

Click the button above to compile your final structured note.