ADD / ADHD Questionnaire - insytepsychiatric.com

ADD / ADHD Questionnaire

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

MonthDayYear
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?

NeverRarelySometimesOftenVery Often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

NeverRarelySometimesOftenVery Often
3. How often do you have problems remembering appointments or obligations?

NeverRarelySometimesOftenVery Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

NeverRarelySometimesOftenVery Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

NeverRarelySometimesOftenVery Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

NeverRarelySometimesOftenVery Often
7. How often do you make careless mistakes when you have to work on a boring or difficult project?

NeverRarelySometimesOftenVery Often
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

NeverRarelySometimesOftenVery Often
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

NeverRarelySometimesOftenVery Often
10. How often do you misplace or have difficulty finding things at home or at work?

NeverRarelySometimesOftenVery Often
11. How often are you distracted by activity or noise around you?

NeverRarelySometimesOftenVery Often
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

NeverRarelySometimesOftenVery Often
13. How often do you feel restless or fidgety?

NeverRarelySometimesOftenVery Often
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?

NeverRarelySometimesOftenVery Often
15. How often do you find yourself talking too much when you are in social situations?

NeverRarelySometimesOftenVery 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?

NeverRarelySometimesOftenVery Often
17. How often do you have difficulty waiting your turn in situations when turn taking is required?

NeverRarelySometimesOftenVery Often
18. How often do you interrupt others when they are busy?

NeverRarelySometimesOftenVery Often
Should be Empty: