ADD / ADHD Questionnaire - insytepsychiatric.com

ADD / ADHD Questionnaire

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Patient Name
Today's Date

Month Day Year
Please answer the questions below, rating yourself on each of the criteria shown using the scale. Select the best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

Never Rarely Sometimes Often Very Often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

Never Rarely Sometimes Often Very Often
3. How often do you have problems remembering appointments or obligations?

Never Rarely Sometimes Often Very Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

Never Rarely Sometimes Often Very Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

Never Rarely Sometimes Often Very Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Never Rarely Sometimes Often Very Often
7. How often do you make careless mistakes when you have to work on a boring or difficult project?

Never Rarely Sometimes Often Very Often
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

Never Rarely Sometimes Often Very Often
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

Never Rarely Sometimes Often Very Often
10. How often do you misplace or have difficulty finding things at home or at work?

Never Rarely Sometimes Often Very Often
11. How often are you distracted by activity or noise around you?

Never Rarely Sometimes Often Very Often
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

Never Rarely Sometimes Often Very Often
13. How often do you feel restless or fidgety?

Never Rarely Sometimes Often Very Often
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?

Never Rarely Sometimes Often Very Often
15. How often do you find yourself talking too much when you are in social situations?

Never Rarely Sometimes Often Very Often
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?

Never Rarely Sometimes Often Very Often
17. How often do you have difficulty waiting your turn in situations when turn taking is required?

Never Rarely Sometimes Often Very Often
18. How often do you interrupt others when they are busy?

Never Rarely Sometimes Often Very Often
Should be Empty: