Tic Disorder Intake Questionnaire

Instructions

Print Report: Click "Generate PDF Report" at any time to create a printable version of your current responses. This does not submit the form.

Submit Assessment: Click "Submit Assessment" when you're ready to submit your completed questionnaire for clinical review. Required fields must be completed.

I consent to this assessment and understand that the information will be used for clinical evaluation purposes. *

First Name *

Last Name *

Date of Birth *

Gender

Phone Number

Email Address

Age when tic symptoms first appeared

Family history of tics or related conditions

Tics Tourette Syndrome OCD ADHD Anxiety None

Current medical conditions

List all current medications (including dosage and frequency)

Previous medications tried for tics

Current Motor Tics (check all that apply) *

Current Vocal Tics (check all that apply)

Describe your most bothersome tics

Motor Tics

Number of motor tics (0-5 scale)

Motor tic frequency (0-5 scale)

Motor tic intensity (0-5 scale)

Motor tic complexity (0-5 scale)

Motor tic interference (0-5 scale)

Vocal Tics

Number of vocal tics (0-5 scale)

Vocal tic frequency (0-5 scale)

Vocal tic intensity (0-5 scale)

Vocal tic complexity (0-5 scale)

Vocal tic interference (0-5 scale)

Overall Impairment

Overall impairment (0-50 scale)

Motor Tic Score: 0/25

Vocal Tic Score: 0/25

YGTSS Total Score: 0/100

PUTS Total Score: 0/36

Interpretation: Not calculated

Psychological Domain: 0/25

Physical Domain: 0/25

Obsessional Domain: 0/25

Cognitive Domain: 0/25

How much do tics affect school/work performance? (1-5 scale)

How much do tics affect social relationships? (1-5 scale)

How much do tics interfere with daily activities? (1-5 scale)

Additional symptoms or conditions (check all that apply)

ADHD OCD Anxiety Disorders Depression Autism Spectrum Disorder Learning Disabilities Sleep Disorders Other

Additional notes or concerns

What are your main treatment goals?

Questions for your healthcare provider

Tic Disorder Intake Questionnaire

Instructions

1. Informed Consent & Demographics

2. Medical History & Family History

3. Current Medications

4. Tic Symptom Assessment

5. Yale Global Tic Severity Scale (YGTSS)

Motor Tics

Vocal Tics

Overall Impairment

6. Premonitory Urge for Tics Scale (PUTS)

7. Quality of Life Assessment

8. Functional Impairment Assessment

9. Additional Symptoms & Comorbidities

10. Summary & Action Plan