ASRS Screening Scale

1

Patient's Name* This field is required.

First Name

Last Name

2

Today's Date* This field is required.

Date

3

Please select the response that best describes how you have felt or conducted yourself over the past 6 months

4

1. How often do you have difficulty concentrating on what people are saying to you even when they are speaking to you directly?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

5

2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

6

3. How often do you have difficulty unwinding and relaxing when you have time to yourself?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

7

4. 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?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

9

6. How often do you depend on others to keep your life in order and attend to details?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

10

Score* This field is required.