• Form

  • Self Report Questionnaire

    ADHD
  • Date of Birth *
     - -
  • Today's Date*
     / /

  • 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, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. 

    • Part A 
    • 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? a question*
    • 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? a question*
    • 3. How often do you have problems remembering appointments or obligations?*
    • 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*
    • 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*
    • 6. How often do you feel overly active and compelled to do things, like you were driven by a motor?*
    • Part B 
    • 7. How often do you make careless mistakes when you have to work on a boring or difficult project?
    • 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?*
    • 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?*
    • 10. How often do you misplace or have difficulty finding things at home or at work?*
    • 11. How often are you distracted by activity or noise around you?*
    • 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*
    • 13. How often do you feel restless or fidgety?*
    • 14. How often do you have difficulty unwinding and relaxing when you have time to yourself?*
    • 15. How often do you find yourself talking too much when you are in social situations?*
    • 16. 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?*
    • 17. How often do you have difficulty waiting your turn in situations when turn taking is required?*
    • 18. How often do you interrupt others when they are busy?*
    • Should be Empty: