Adolescent ADHD Self-Report Form
Complete this form yourself to describe your current attention, symptoms, and how they affect your daily life.
Patient Information
Please complete this form yourself. If you need help reading or understanding any question, ask a parent, guardian, or clinician for assistance.
First Name
*
Last Name
*
Date of Birth
*
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Month
-
Day
Year
Date
Email
example@example.com
Today’s Date
*
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Month
-
Day
Year
Date
ADHD Symptom Checklist
How often do you have trouble paying attention in class?
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Never
Sometimes
Often
Very Often
How often do you forget homework, school materials, or personal items?
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Never
Sometimes
Often
Very Often
How often do you fidget, squirm, or feel restless when you are supposed to sit still?
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Never
Sometimes
Often
Very Often
How often do you act without thinking or interrupt others?
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Never
Sometimes
Often
Very Often
How often do you have trouble keeping your backpack, desk, or room organized?
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Never
Sometimes
Often
Very Often
How often do you have trouble following multi-step instructions?
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Never
Sometimes
Often
Very Often
Functional Impairment Ratings
School: Completing homework on time
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No problem
Mild problem
Moderate problem
Severe problem
School: Staying organized with school materials
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No problem
Mild problem
Moderate problem
Severe problem
School: Following instructions in class
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No problem
Mild problem
Moderate problem
Severe problem
School: Turning in assignments accurately and on time
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No problem
Mild problem
Moderate problem
Severe problem
Home/Family: Completing chores or responsibilities
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No problem
Mild problem
Moderate problem
Severe problem
Home/Family: Getting along with family members
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No problem
Mild problem
Moderate problem
Severe problem
Home/Family: Following household rules and routines
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No problem
Mild problem
Moderate problem
Severe problem
Social/Peer Relationships: Making or keeping friends
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No problem
Mild problem
Moderate problem
Severe problem
Social/Peer Relationships: Waiting my turn in conversations or activities
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No problem
Mild problem
Moderate problem
Severe problem
Social/Peer Relationships: Handling conflict with peers
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No problem
Mild problem
Moderate problem
Severe problem
Self-Esteem: Feeling good about my abilities
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No problem
Mild problem
Moderate problem
Severe problem
Self-Esteem: Feeling frustrated or discouraged because of attention or behavior problems
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No problem
Mild problem
Moderate problem
Severe problem
Self-Esteem: Confidence in completing tasks independently
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No problem
Mild problem
Moderate problem
Severe problem
Self-Esteem: Worrying about how others see me at school or with friends
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No problem
Mild problem
Moderate problem
Severe problem
Treatment and Open Response
Are you currently receiving any treatment or medication for attention or focus concerns?
*
No treatment or medication
Medication only
Therapy or counseling only
Both medication and therapy/counseling
Not sure
Other
Describe your current concerns in your own words
*
Submit
Should be Empty: