Adult ADHD Self-Report Checklist
Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, select the box that best describes how you have felt and conducted yourself over the past 6 months. Thank you!
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Adult ADHD Questionnaire
Over the last 6 months, how have you felt and conducted yourself in the following situations?
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have difficulty getting things in order when you have to do a task that requires organization?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have problems remembering appointments or obligations?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you feel overly active and compelled to do things, like you were driven by a motor?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you make careless mistakes when you have to work on aboring or difficult project?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have difficulty concentration on what people say to you, even when they are speaking directly to you?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you misplace or have difficulty finding things at home or at work?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often are you distracted by activity or noise around you?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you feel restless or fidgety?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have difficulty unwinding and relaxing when you have time to yourself?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you find yourself talking too much when you are in social situations?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you have difficulty waiting your turn in situations when turn taking is required?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
How often do you interrupt others when they are busy?
*
Please Select
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very Often
Please sign to confirm that the information you provided is truthful and accurate.
*
Clear
Please verify that you are human.
*
Submit
Should be Empty: