ADHD Questionnaire ADHD Assessment Questionnaire * Input based on your choices: Often, Not often First Name Last Name Phone (###) ### #### Email * INATTENTION 1. How often do you makes careless mistakes/lacks attention to detail? Often Not often 2. How often do you lack sustained attention in tasks or play activities? Often Not often 3. How often are you a poor listener, even in the absence of obvious distraction? Often Not often 4. How often do you fail to follow through on tasks and instructions? Often Not often 5. How often do you have difficulty with organization, time management, and deadlines? Often Not often 6. How often do you avoid tasks requiring sustained mental effort? Often Not often 7. How often do you lose things necessary for tasks or activities? Often Not often 8. How often are you easily distracted (including unrelated thoughts)? Often Not often 9. How often are you forgetful in daily activities? Often Not often IMPULSIVITY/HYPERACTIVITY 1. How often do you fidget, tap hands, or squirms in seat? Often Not often 2. How often do you leave your seat in situations when remaining seated is expected? Often Not often 3. How often do you engage in excessive running/climbing or feelings of restlessness? Often Not often 4. How often do you have difficulty with quiet, leisure activities? Often Not often 5. How often do you unconsciously engage in excessive talking? Often Not often 6. How often do you blurt out answers before questions are even completed? Often Not often 7. How often do you have difficulty waiting turn? Often Not often 8. How often do you interrupt or intrudes on others? Often Not often 9. How often do jump from task to task and projects to project without completing the first? Often Not often 10. How often do you have difficulty keeping your immediate surrounding clean and tidy? Often Not often 11. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? Often Not often 12. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? Often Not often 13. How often do you have difficulty unwinding and relaxing when you have time to yourself? Often Not often 14. When you are 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? Often Not often 15. How often do you find yourself talking too much when you are in social situations? Often Not often 16. How often do you interrupt others when they are busy? Often Not often 17. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? Often Not often 18. How often do you procrastinate or postpone completing a required task to the last meeting? Often Not often When did you have a Psychological Evaluation to confirm/rule out ADHD? What medication have you taken for ADHD in the past? Who prescribed this medication for you? What State did you live when the medication was prescribed for you? Thank you!
