Adult ADHD Screener

Name*

First NameLast Name

Visit date*

Are you currently on medication for attention deficit hyperactivity disorder (ADHD)?

YesNo

Select the choice that best describes how you have felt and conducted yourself over the past 6 months WITHOUT medication. If you are currently on medication, imagine yourself before you started medication or on days you don't take medication.

	Never	Rarely	Sometimes	Often	Very often
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands and feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?

Score

A score 4 or greater indicates that your symptoms may be consistent with Adult ADHD. It may be beneficial for you to talk with your healthcare provider about an evaluation.

Now please answer the same questions based on how you would respond WITH medication.

	Never	Rarely	Sometimes	Often	Very often
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands and feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?

Are you living with Adult ADHD?

Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener