ADHD Supplemental Questionnaire

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Before You Begin

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The ADHD assessment includes a proprietary questionnaire that is supplemental to the general patient intake forms. It is not an online scoring tool, but a comprehensive investigation to evaluate the presence and severity of ADHD symptoms, as well as their effects on different aspects of your life, such as academic and professional performance, social interactions, and daily activities. Providers use your answers to carefully consider medical, psychiatric, and psychological factors that could be potentially contributing to and influencing the presentation of symptoms and to help distinguish ADHD from other conditions with similar symptoms. Patients are also offered in-depth education on the neurophysiology of the condition and sound reasoning on whether to prioritize ADHD or any co-occurring challenges. Conducting a comprehensive analysis is essential to ensure that we accurately diagnose and recommend the most suitable treatment and interventions. Not all patients will be candidates for stimulants based on medical and psychiatric comorbidities.

The out-of-pocket cost for new diagnostic ADHD diagnostic assessment is $300.00. The assessment fee is non-refundable and must be paid before proceeding to the assessment. Your consultation is still subject to any copay or deductible outlined in your insurance coverage or the cash fee schedule for private pay patients. Insurance companies do not cover private comprehensive ADD/ADHD assessment and reporting services.

For patients who have already undergone a neuropsychological assessment and/or have documentation of prior diagnosis and treatment of ADHD with stimulants for at least one year, your assessment fee can be waived if you provide past medical records. Without documentation, you will need to undergo a new diagnostic evaluation.
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Name* This field is required.
First Name
Last Name
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Do you wish to proceed with paying for the questionnaire at this time?* This field is required.
YESNO
5
ADHD Diagnostic Evaluation* This field is required.
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The following questionnaire adapts to your answers and triggers clarifying questions when needed. The form takes approximately 20 minutes to complete so please allow enough time to complete the form once you start. The questions are best view on a desktop but are designed to be mobile-friendly. Please submit at your earliest convenience but no later than 5pm the day before your consultation to allow us time to review in advance and best prepare for your visit. We look forward to getting to know you!
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Email* This field is required.
example@example.com
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Date* This field is required.
Month
Day
Year
9
Do you have persistent difficulty maintaining routine daily adult respsonsibilities?* This field is required.
I don't keep up with housekeeping tasks in a regular, consistent manner.
My home/office are filled with disorganized piles of papers.
My wardrobe is disorganized and in disarray.
I typically neglect making routine medical/dental appointments.
I neglect to take care of routine automobile maintenance.
Laundry is done at the last possible moment.
I wait until my car is nearly out of gas before filling the tank.
My life is filled with numerous, avoidable crises.
None of the above
Other
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How is your financial management?* This field is required.
I have difficulty managing my money.
I have large credit card debt.
I tend to file my tax forms late.
My financial record-keeping is chaotic.
I have a poor credit rating.
None of the above
Other
11
Do you have any of these problematic lifestyle habits?* This field is required.
I am a “night owl” and rarely go to sleep at a “reasonable” hour.
I often eat to calm myself.
I keep myself going throughout the day with coffee, tea, and colas.
I have used cigarettes to help increase my concentration.
None of the above
Other
12
Do you have persistent difficulty staying awake in the day?
I am not fully awake and alert until several hours after I rise in the morning.
I use sugar and/or caffeine to keep myself going during the day.
If my life circumstances allowed it, I would take a daily afternoon nap.
On weekends, I sleep late or nap to catch up on my sleep.
None of the above
Other
13
How is your driving?
Never
Rarely
Sometimes
Often
Always
I lose track of where I am going and often miss turns, exits, or traffic signs.
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I forget where I am driving to.
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I have trouble driving in the correct lane.
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I drift into other lanes.
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I have difficulty merging into traffic.
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I forget to make appropriate adjustments in speed.
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I do not maintain an appropriate distance between myself and the driver in front of me.
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I cannot maintain my speed when I am unable to stay calm.
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My speed and handling makes others uncomfortable.
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I yell, swear, or make gestures at the driver/drivers who made me nervous.
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During bad weather, I generally don't adjust my driving as much as I should.
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I get honked at more than others.
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I have gotten more speeding tickets than people around me.
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I lose track of where I am going and often miss turns, exits, or traffic signs.
I forget where I am driving to.
I have trouble driving in the correct lane.
I drift into other lanes.
I have difficulty merging into traffic.
I forget to make appropriate adjustments in speed.
I do not maintain an appropriate distance between myself and the driver in front of me.
I cannot maintain my speed when I am unable to stay calm.
My speed and handling makes others uncomfortable.
I yell, swear, or make gestures at the driver/drivers who made me nervous.
During bad weather, I generally don't adjust my driving as much as I should.
I get honked at more than others.
I have gotten more speeding tickets than people around me.
Never
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Rarely
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Always
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Never
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Always
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Never
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Rarely
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Often
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Always
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Never
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Rarely
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Always
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Never
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Always
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Never
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Rarely
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Often
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Always
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Never
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Rarely
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Often
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Always
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Never
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Rarely
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Sometimes
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Often
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Always
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Never
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Rarely
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Sometimes
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Often
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Always
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Never
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Rarely
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Sometimes
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Often
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Always
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Never
Row 10, Column 0
Rarely
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Sometimes
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Often
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Always
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Never
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Rarely
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Sometimes
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Often
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Always
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Never
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Rarely
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Often
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Always
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Did you have any persistent problematic behaviors growing up?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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YesNo
YesNo
YesNo
losing temper
actively defying or refusing s to go along with adults’ requests or rules
arguing with figures of authority (parents, teachers, coaches)
intolerance with being turned down or rejected
deliberately annoying people
blaming others for your mistakes or misbehaviors
feeling vengeful and trying to teach someone a lesson
feeling touchy or easily annoyed by others
feeling spiteful and try to get even
bullying, threatening, or intimidating others
getting involved in physical fights
lying to get out of trouble or to avoid obligations ("con" others)
skipping school without permission
physical cruelty to people
physical cruelty to animals
stealing/shoplifting
deliberately destroying others’ property
using weapon that can cause serious harm (bat, knife, brick, gun)
deliberately setting fires to cause damage
breaking into someone else’s home, business, or car
running away from home overnight
forcing someone into sexual activity
losing temper
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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YesNo
YesNo
YesNo
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Did you have any social/interpersonal issues growing up?
Agree
Disagree
I felt shy and self-conscious around my classmates.
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Even when I had something to say, I rarely raised my hand to volunteer in class.
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I had only a few friends during school years.
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It was hard for me to keep up with the conversation of a group of classmates.
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I was very sensitive to teasing.
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I felt shy and self-conscious around my classmates.
Even when I had something to say, I rarely raised my hand to volunteer in class.
I had only a few friends during school years.
It was hard for me to keep up with the conversation of a group of classmates.
I was very sensitive to teasing.
Agree
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Disagree
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Agree
Row 1, Column 0
Disagree
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Agree
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Disagree
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Agree
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Disagree
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Agree
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Disagree
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How would you describe yourself socially now?
Agree
Disagree
I can initiate social conversations with relative ease.
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I like to connect with and meet people.
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I am considered an energizer around my peers because of the energy I infuse into my environment.
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I am very accepting of others flaws.
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I can initiate social conversations with relative ease.
I like to connect with and meet people.
I am considered an energizer around my peers because of the energy I infuse into my environment.
I am very accepting of others flaws.
Agree
Row 0, Column 0
Disagree
Row 0, Column 1
Agree
Row 1, Column 0
Disagree
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Agree
Row 2, Column 0
Disagree
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Agree
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Disagree
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Do you have any of the following interpersonal challenges?
I can't seem to maintain friendships over the long term.
I often misread people.
I am not a good listener and interrupt or think about other things while others are talking.
My lateness and disorganization have been major points of conflict in important relationships.
None of the above
18
How were you in your school, relative to your peers in school?
Less
Same
More
Time spent studying
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Attendance
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Row 1, Column 2
Grades
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Participation in sports
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Participation in extracurriculars
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Popularity
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Following rules
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Taking risks
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Time spent studying
Attendance
Grades
Participation in sports
Participation in extracurriculars
Popularity
Following rules
Taking risks
Less
Row 0, Column 0
Same
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More
Row 0, Column 2
Less
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Same
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More
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Less
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Same
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More
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Less
Row 3, Column 0
Same
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More
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Less
Row 4, Column 0
Same
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More
Row 4, Column 2
Less
Row 5, Column 0
Same
Row 5, Column 1
More
Row 5, Column 2
Less
Row 6, Column 0
Same
Row 6, Column 1
More
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Less
Row 7, Column 0
Same
Row 7, Column 1
More
Row 7, Column 2
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When doing school assignments, did you regularly...
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
handed in my homework late?
forget to complete homework assignments?
forget to hand in completed assignments?
have trouble keeping track of assignments, long-term projects, and due dates?
need peers to keep you on track to complete a large group project?
run out of time for in-class seatwork even when everyone else finished?
studied or did homework late into the night?
get by doing things at the last minute?
handed in my homework late?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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20
When taking tests, did you regularly...
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
make a study schedule?
turn down leisure activities to stay on your study schedule?
forget test dates?
forget to review concepts or materials required?
run out of time before completing the test?
feel confused about the directions?
lose points for incomplete answers?
make a study schedule?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 7
21
How is your reading?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I rarely read for pleasure.
While reading, I can concentrate only if the material is very interesting to me.
I read much slower compared to others.
I must almost always reread text in order to comprehend it.
I usually cannot recall information that I have read just once.
After reading a chapter in a book, I generally cannot answer any follow up the questions right after.
I often misread telling time on a clock.
I rarely read for pleasure.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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22
Do you have any of these writing habits?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I have difficulty organizing my thoughts in writing, even when I am very familiar with the subject.
I am much more comfortable explaining something verbally than in writing.
My handwriting is messy.
Spelling or writing correctly is always difficult for me.
I have lots of ideas, but can't organize them well when writing.
I can very clearly explain what I know verbally, but just can’t get it down on paper.
I have difficulty organizing my thoughts in writing, even when I am very familiar with the subject.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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Do you have any persistent problems with gross or fine motor skills?
YesNo
YesNo
YesNo
YesNo
YesNo
Sense of surrounding space
Balance
Coordination
I tended to bump into things – corners of tables, door frames,
I was physically awkward and did poorly in sports.
Sense of surrounding space
YesNo
YesNo
YesNo
YesNo
YesNo
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How organized were your backpack, locker, study areas?
Very neat and organized
Somewhat messy but I always knew where items were when I needed them
Very messy where I often misplaced necessary papers, instructions, and materials
25
Perception of Self* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I consider myself successful according to my intelligence.
I consider myself successful according to my level of education.
I feel disappointed in my achievements.
I feel that I am viewed negatively.
I am very sensitive to criticism.
I tend to hide many aspects of my life, fearing that I’ll be judged negatively.
People think too highly of me, and I fear that I’ll be “found out.”
I have felt easily demoralized by my failures.
I have often felt “stupid” because I couldn’t seem to accomplish things that others could.
I consider myself successful according to my intelligence.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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How sensitive are you to feelings of rejection?* This field is required.
Never
Rarely
Sometimes
Often
Always
Do you experience sudden, intense bouts of rage when your feelings are hurt?
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Do you experience sudden, intense bouts of extreme sadness when you think you have been rejected or criticized?
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Are you your own harshest critic?
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Do you feel anxious in social situations because you assume that no one likes you?
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Do you pass up opportunities or avoid starting projects because you’re afraid you’ll fail?
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Do you consider yourself a “people pleaser,” going above and beyond to get on someone’s good side?
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Have you been called “overly sensitive” or a “head case” because of your strong emotional reactions?
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Do you ever experience your emotions as a physical sensation, as though you’ve been punched in the chest or physically “wounded?”
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Do you feel shame about the “lack of control” you have over your emotions?
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Do you shy away from close friendships or romantic relationships, because you worry that if people “know the real you,” they won’t like you?
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Do you assume the worst in commonplace interactions — worrying you will be fired every time your boss calls you in to her office, for instance?
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Do you avoid meeting new people or trying new things because your fear of rejection and criticism is so strong?
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Do you experience sudden, intense bouts of rage when your feelings are hurt?
Do you experience sudden, intense bouts of extreme sadness when you think you have been rejected or criticized?
Are you your own harshest critic?
Do you feel anxious in social situations because you assume that no one likes you?
Do you pass up opportunities or avoid starting projects because you’re afraid you’ll fail?
Do you consider yourself a “people pleaser,” going above and beyond to get on someone’s good side?
Have you been called “overly sensitive” or a “head case” because of your strong emotional reactions?
Do you ever experience your emotions as a physical sensation, as though you’ve been punched in the chest or physically “wounded?”
Do you feel shame about the “lack of control” you have over your emotions?
Do you shy away from close friendships or romantic relationships, because you worry that if people “know the real you,” they won’t like you?
Do you assume the worst in commonplace interactions — worrying you will be fired every time your boss calls you in to her office, for instance?
Do you avoid meeting new people or trying new things because your fear of rejection and criticism is so strong?
Never
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Rarely
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Sometimes
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Often
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Always
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Never
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Rarely
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Often
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Always
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Never
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Rarely
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Often
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Always
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Never
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Rarely
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Sometimes
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Often
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Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
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Sometimes
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Often
Row 4, Column 3
Always
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Never
Row 5, Column 0
Rarely
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Sometimes
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Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
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Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Rarely
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Sometimes
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Often
Row 7, Column 3
Always
Row 7, Column 4
Never
Row 8, Column 0
Rarely
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Sometimes
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Often
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Always
Row 8, Column 4
Never
Row 9, Column 0
Rarely
Row 9, Column 1
Sometimes
Row 9, Column 2
Often
Row 9, Column 3
Always
Row 9, Column 4
Never
Row 10, Column 0
Rarely
Row 10, Column 1
Sometimes
Row 10, Column 2
Often
Row 10, Column 3
Always
Row 10, Column 4
Never
Row 11, Column 0
Rarely
Row 11, Column 1
Sometimes
Row 11, Column 2
Often
Row 11, Column 3
Always
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How often do you...* This field is required.
Never
Rarely
Sometimes
Often
Always
feel overly active and compelled to do things, like you were driven by a motor?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
fidget or doodle?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
tap or shake your hands or feet when you have to sit down for a long time?
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Row 2, Column 3
Row 2, Column 4
make excuses to leave your seat in meetings or other situations in which you are expected to remain seated?
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Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
have difficulty unwinding and relaxing when you have time to yourself?
Row 4, Column 0
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Row 4, Column 3
Row 4, Column 4
find yourself talking too much when you are in social situations?
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Row 5, Column 3
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talk excessively in play or leisurely activities where you are expected to engage quietly?
Row 6, Column 0
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Row 6, Column 2
Row 6, Column 3
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talk so fast that others "can't get a word in."?
Row 7, Column 0
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Row 7, Column 3
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pick up and drop hobbies or interests without investing enough time in them?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
feel overly active and compelled to do things, like you were driven by a motor?
fidget or doodle?
tap or shake your hands or feet when you have to sit down for a long time?
make excuses to leave your seat in meetings or other situations in which you are expected to remain seated?
have difficulty unwinding and relaxing when you have time to yourself?
find yourself talking too much when you are in social situations?
talk excessively in play or leisurely activities where you are expected to engage quietly?
talk so fast that others "can't get a word in."?
pick up and drop hobbies or interests without investing enough time in them?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
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Sometimes
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Often
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Always
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Never
Row 2, Column 0
Rarely
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Sometimes
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Often
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Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
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Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Sometimes
Row 7, Column 2
Often
Row 7, Column 3
Always
Row 7, Column 4
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Sometimes
Row 8, Column 2
Often
Row 8, Column 3
Always
Row 8, Column 4
1 of 9
28
Hyperactivity* This field is required.
YesNo
YesNo
YesNo
I seem to need less sleep than others.
I have a high energy level compared to others.
My activity level makes the people around me uncomfortable or suspicious.
I seem to need less sleep than others.
YesNo
YesNo
YesNo
1 of 3
29
How often do you...* This field is required.Distractibility
Never
Rarely
Sometimes
Often
Always
wander from one task to the next as something catches your attention?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
jump from topic to topic in conversation, forgetting what you started to say?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
have difficulty concentrating when there is noise or conversation around you, even when it doesn't bother others?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
have difficulty getting back on topic after an interruption?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
have difficulty recalling the names of common objects or others?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
feel distracted by external stimuli such as environmental sounds, lights, or images?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
feel distracted by internal stimuli such as your own thoughts?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
immediately forget to do thing that you intended to do?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
wander from one task to the next as something catches your attention?
jump from topic to topic in conversation, forgetting what you started to say?
have difficulty concentrating when there is noise or conversation around you, even when it doesn't bother others?
have difficulty getting back on topic after an interruption?
have difficulty recalling the names of common objects or others?
feel distracted by external stimuli such as environmental sounds, lights, or images?
feel distracted by internal stimuli such as your own thoughts?
immediately forget to do thing that you intended to do?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Sometimes
Row 7, Column 2
Often
Row 7, Column 3
Always
Row 7, Column 4
1 of 8
30
How often do you ...* This field is required.Inattention
Never
Rarely
Sometimes
Often
Always
make careless mistakes when you have to work on a boring or difficult project?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
have difficulty keeping your attention when you are doing boring or repetitive work?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
have difficulty managing sequential tasks?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
have difficulty concentrating on what people say to you, even when they are speaking to you directly?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
overlook key details in a set of instructions, a recipe, or a list of requirements/deadlines?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
have difficulty remembering multi-step directions or multi-item lists?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
forget routine appointments or obligations?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
make careless mistakes when you have to work on a boring or difficult project?
have difficulty keeping your attention when you are doing boring or repetitive work?
have difficulty managing sequential tasks?
have difficulty concentrating on what people say to you, even when they are speaking to you directly?
overlook key details in a set of instructions, a recipe, or a list of requirements/deadlines?
have difficulty remembering multi-step directions or multi-item lists?
forget routine appointments or obligations?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
1 of 7
31
How often do you ...* This field is required.
Never
Rarely
Sometimes
Often
Always
have difficulty getting things in order when you have to do a task that requires organization?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
have trouble following and completing schoolwork, chores, or duties in the workplace?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort or thought?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
leave large projects unfinished and "in progress"?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
procrastinate and resist doing everyday tasks that are unappealing (showering, brushing teeth, eating)?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
do you what you want to do instead of what you need to do?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
have trouble wrapping up the final details of a project, once the challenging parts have been done?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
have difficulty getting things in order when you have to do a task that requires organization?
have trouble following and completing schoolwork, chores, or duties in the workplace?
avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort or thought?
leave large projects unfinished and "in progress"?
procrastinate and resist doing everyday tasks that are unappealing (showering, brushing teeth, eating)?
do you what you want to do instead of what you need to do?
have trouble wrapping up the final details of a project, once the challenging parts have been done?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
1 of 7
32
Organization* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I have to write things down to remember them.
My home is cluttered and messy.
I can’t seem to organize my paperwork – either at home or at work.
Despite my best intentions, it is often hard for me to get started on a project.
Getting started is much easier when I work with someone else.
I stay on track better when I work with others than when I work alone.
I have to write things down to remember them.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 6
33
Stimulation* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I am easily bored.
I am more interested in the unknown than the predictable.
I do not do well with change in my life.
I have a very limited and specific interests and activities.
I prefer a predictable and stable routine.
Everyday things seem like “too much trouble” to me.
I thrive on stimulation and change around me.
I rarely stick with a goal or project that takes effort.
When I'm really concentrating, I don’t hear what people say to me.
It is difficult for me to stop an activity when it is time to do something else.
I am easily bored.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 10
34
How often do you...* This field is required.
Never
Rarely
Sometimes
Often
Always
have difficulty time gauging the time it will take to do something and/or the time it will take to get somewhere?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
overcrowd your schedule and overcommit yourself?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
dawdle and lose track of time?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
run late because you try to squeeze in “one last thing"?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
lose, misplace or damage something that's necessary in order to get things done (e.g., your phone, eyeglasses, paperwork, wallet, keys, etc.)?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
run late for scheduled activities and end up feeling frantic?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
put things off until the last minute?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
miss deadlines you set for yourself?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
have difficulty time gauging the time it will take to do something and/or the time it will take to get somewhere?
overcrowd your schedule and overcommit yourself?
dawdle and lose track of time?
run late because you try to squeeze in “one last thing"?
lose, misplace or damage something that's necessary in order to get things done (e.g., your phone, eyeglasses, paperwork, wallet, keys, etc.)?
run late for scheduled activities and end up feeling frantic?
put things off until the last minute?
miss deadlines you set for yourself?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Sometimes
Row 7, Column 2
Often
Row 7, Column 3
Always
Row 7, Column 4
1 of 8
35
How do you go about the day?* This field is required.
I generally plan my day to where I feel prepared for events as they happen.
I rarely plan my day and typically react to events as they occur.
36
How do you go about a complex project or task?* This field is required.
I meticulously plan most details ahead of time.
I just try to accomplish what's next and worry about the rest as it comes.
37
What kind of social plans do you prefer?* This field is required.
I am very comfortable with making and changing plans as I go.
I prefer social activities that are thoroughly planned well in advance.
38
Compared to your peers, how often have you switched things in life?* This field is required.
Less
Same
More
Romantic partners
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Friends
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Roommates/residences
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Field of study
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Jobs
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
careers
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Romantic partners
Friends
Roommates/residences
Field of study
Jobs
careers
Less
Row 0, Column 0
Same
Row 0, Column 1
More
Row 0, Column 2
Less
Row 1, Column 0
Same
Row 1, Column 1
More
Row 1, Column 2
Less
Row 2, Column 0
Same
Row 2, Column 1
More
Row 2, Column 2
Less
Row 3, Column 0
Same
Row 3, Column 1
More
Row 3, Column 2
Less
Row 4, Column 0
Same
Row 4, Column 1
More
Row 4, Column 2
Less
Row 5, Column 0
Same
Row 5, Column 1
More
Row 5, Column 2
1 of 6
39
What is likely the most common reason for your indecisiveness in day to day tasks?* This field is required.
Not understanding the options
Too many options
Hesitation on time commitment
Feeling uncomfortable with the finality of the decision
Afraid of a bad outcome
Difficulty in prioritizing importance
40
What is your motivation style?* This field is required.
Intrinsically motivated to pursue fun, curiosity, or challenge
Extrinsically motivated based on results, pressures or rewards
41
Field of Work and Role* This field is required.
YesNo
YesNo
YesNo
YesNo
Do you like the field of study or work that you are in?
Do you like the role that you are in?
Do you think your role or field is the best fit for your talents and skills?
Do you think your role is the best fit for how you work and process information?
Do you like the field of study or work that you are in?
YesNo
YesNo
YesNo
YesNo
1 of 4
42
How is your frustration tolerance?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I generally hate waiting on others.
I hate repeating myself.
I become easily frustrated and angry in traffic.
I lose my temper if my environment is noisy or people are me are argumentative.
I often quit a task if I encounter difficulties.
I do not like to train or teach others.
I abruptly distance myself from frustrating situations.
I generally hate waiting on others.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 7
43
Do you have any obsessive tendencies in your handling of tasks?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
Even in unimportant tasks, I feel compelled to do a perfect, micro-detailed job.
I have strong perfectionist tendencies.
In my efforts to do a good job, I seem to make things more complicated than they need to be.
There are periods when I become frustratingly obsessed by an irrational thought or concern.
I dedicate more time than is necessary to a project to make sure my work has no mistakes (and is above reproach).
Even in unimportant tasks, I feel compelled to do a perfect, micro-detailed job.
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 5
44
Can you identify any benefits of your symptoms ?* This field is required.(i.e.creativity, spontaneity, humility, courage)
Huge
Large
Normal
Small
Ok
Ok
45
You have declined the ADHD diagnostic assessment. You are still scheduled for your upcoming visit (which will exclude consideration of ADHD). If you reconsider completing the form at a later date, please let your provider know.

Thank you.
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