Wender Utah Rating Scale for the Attention Deficit Hyperactivity Disorder
Date of Service
*
 -
Month
 -
Day
Year
Date of Visit
Patient Name
*
First Name
Last Name
Gender
For each of the 61 items, check the box that best describes your behavior:
Active, restless, always on the go
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Afraid of things
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Concentration problems, easily distracted
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Anxious, worrying
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Nervous, fidgety
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Inattentive, daydreaming
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Hot- or short-tempered, low boiling point
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Shy, sensitive
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Temper outbursts, tantrums
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble with stick-to-it-tiveness, not following
*
Not at all
Mildly
Moderately
Quite a bit
Very much
through. Failing to finish things started
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Stubborn, strong-willed
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Sad or blue, depressed, unhappy
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Incautious, dare-devilish, involved in pranks
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Not getting a kick out of things, dissatisfied with life
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Disobedient with parents, rebellious, sassy
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Low opinion of myself
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Irritable
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Outgoing, friendly, enjoyed company of people
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Sloppy, disorganized
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Moody, ups and downs
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Angry
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Friends,popular
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Well-organized, tidy, neat
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Acting without thinking, impulsive
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Tendency to be immature
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Guilty feelings, regretful
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Losing control of myself
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Tendency to be or act irrational
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Unpopular with other children, didn't keep friends for long, didn't get along with other children
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Poorly coordinated, did not participate insports
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Afraid of losing control of self
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Well-coordinated, picked first in games
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Tomboyish (for women only)
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Running away from home
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Getting into fights
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Teasing other children
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Leader, bossy
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Difficulty getting awake
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Follower, led around toomuch
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble seeing things from someone else'spoint of view
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble with authorities, trouble with school,visits to principal's office
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble with police, bookedconvicted
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Medical problems as a child
Headaches
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Stomachaches
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Constipation
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Diarrhea
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Food Allergies
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Other allergies
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Bedwetting
*
Not at all
Mildly
Moderately
Quite a bit
Very much
As a child in school I was (or had)
Overall a good student, fast
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Overall a poor student, slow learner
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Slow in learning to read
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Slow reader
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble reversing letters
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Problems with spelling
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Trouble with mathematics or numbers
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Bad handwriting
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Able to read pretty well but never really enjoyed reading
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Not achieving up to potential
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Repeating grades
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Suspended or expelled
*
Not at all
Mildly
Moderately
Quite a bit
Very much
Total Score
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