Current Symptom Scale - Self Report Form
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Who should form be sent to/who is your appointment with?
*
Agganis, Georgia
Aldrich, Meghan
Amin, Priyal
Athanasiou, Andreas
Balestrieri, Karen
Coleman, Russell
Daly, James
Eagan, Joan
Foley, Megan
Goharfar, Behzad
Grossman, Emily
Hall, Alexandra
Hiltunen, Karen
Hohmann, Deanna
Jackson, Patricia
Jensen, Susan
Jones, Eliza
Kelleher, Susan
Laurin Kinney, Jayne
Leonhardt, Julie Bonner
Narayan, Sara
Oliver, Dana
Scott, Kendra
Sheehy, James
Stimpson, Devin
Suriani, Christine
Triehy-Kreitler, Ashley
Voute, Susan
Wilson, Kathryn
*** Other ***
Please check the response next to each item that best describes your behavior during the past week.
Never or Rarely
Sometimes
Often
Very Often
1 Fail to give close attention to details or make careless mistakes in my work
2 Fidget with hands or feet or squirm in seat
3 Have difficulty sustaining my attention in tasks or fun activities
4 Leave my seat in situations in which seating is expected
5 Don’t listen when spoken to directly
6 Feel restless
7 Don’t follow through on instructions and fail to finish work
8 Have difficulty engaging in leisure activities or doing fun things quietly
9 Have difficulty organizing tasks and activities
10 Feel “on the go” or “driven by a motor”
11 Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort
12 Talk excessively
13 Lose things necessary for tasks or activities
14 Blurt out answers before questions have been completed
15 Am easily distracted
16 Have difficulty awaiting turn
17 Am forgetful in daily activities
18 Interrupt or intrude on others
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