ADHD Observer Questionnaire Form

ADHD Observer Questionnaire Form

(ASRS-O)
Client Name

First NameLast Name
Client DOB

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Observer Name

First NameLast Name
Observer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Observer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Observer Email
example@example.com
What is your relationship to the above individual
How many years and months have you known the above individual.
Do you authorize a provider from Five-Star Integrated Health Services to contact you.
Please answer the questions below, rating this person based on your observations over the past 6 months
- 1. How often does this person have trouble wrapping up the final details of a project, once the challenging parts have been done?
- Examples/details
- 2. How often does this person have issues getting things in order when they have to do a task that requires organization?
- Examples/details
- 3. How often does this person have problems remembering appointments and obligations?
- Examples/details
- 4. When this person has a task that requires a lot of thought, how often do they avoid or delay getting started?
- Examples/details
- 5. How often does this person fidget or squirm with their hands and feet when they have to sit down for a long time?
- Examples/details
- 6. How often does this person seem overly active and compelled to do things, as if they were driven by a motor?
- Examples/details
- Additional Information optional
- 7. How often does this person makes careless mistakes when they have to work on a boring or difficult project?
- Examples/details
- 8. How often does this person have difficulty keeping their attention when doing boring or repetitive work?
- Examples/details
- 9. How often does this person seem overly active and compelled to do things, as if they were driven by a motor?
- Examples/details
- 10. How often does this person misplace or has difficulty finding things at home or at work?
- Examples/details
- 11. How often is this person distracted by activity or noise around them?
- Examples/details
- 12. How often does this person leave their seat in meetings or other situations in which they are expected to remain seated?
- Examples/details
- 13. How often does this person appear restless or fidgety?
- Examples/details
- 14. How often does this person have difficulty unwinding and relaxing when they have time to themselves?
- Examples/details
- 15. How often does this person talk too much when in socialsituations?
- Examples/details
- 16. When this person is in a conversation, how often do they finish the sentences of the people they are talking to, before they can finish them themselves?
- Examples/details
- 17. How often does this person have difficulty waiting theirturn in situations when turn taking is required?
- Examples/details
- 18. How often does this person interrupt others?
- Examples/details
- Additional Information
  If there is additional information relevant to the above situation? If so, Please describe:
- Observer Name
  
  First NameLast Name
- Signature
- Should be Empty: