• Form 2: ADHD Symptom Questionnaire

  • Part 1: Symptoms of attention-deficit (DSM-5 criterion A1)

    Instructions: symptoms in adulthood must have been present for at least 6 months. The symptoms in childhood relate to the age of 5-12 years. For a symptom to be ascribed to ADHD, it should have a chronic trait-like course and should not be episodic.

  • A1 - Do you often fail to give close attention to details, or do you make careless mistakes in your work or during other activities?

    And how was that during childhood (in schoolwork or during other activities)?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A2 - Do you often have difficulty sustaining your attention in tasks?

    And how was that during childhood (in play activities)?
  • Examples Adulthood*

  • * Unless the subject is found to be really interesting (e.g. computer or hobby) 

  • Symptom Present?
  • Examples Childhood:*

  • * Unless the subject is found to be really interesting (e.g. computer or hobby) 

  • Symptom Present?

  • A3 - Does it often seem as though you are not listening when you are spoken to directly?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Childhood Examples*
  • Symptom Present?

  • A4 - Do you often not follow through on instructions and often fail to finish chores or duties in the workplace?

    And how was that during childhood (in schoolwork)?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A5 - Do you often find it difficult to organise tasks and activities?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A6 - Do you often avoid (or do you dislike, or are you reluctant to engage in) tasks that require sustained mental effort?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A7 - Do you often lose things that are necessary for tasks or activities?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A8 - Are you often easily distracted by extraneous stimuli?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • A9 - Are you often forgetful in daily activities?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • Part 2: Symptoms of hyperactivity-impulsivity (DSM-5 Criterion A2)

    Instructions: the symptoms in adulthood must have been present for at least 6 months. The symptoms in childhood relate to the age of 5-12 years. For a symptom to be ascribed to ADHD it should have a chronic trait-like course and should not be episodic.

  • H/I 1 - Do you often fidget with or tap hands or feet, or do you often squirm in your seat?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 2 - Do you often leave your seat in situations where it is expected that you remain seated?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 3 - Do you often feel restless?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 4 - Do you often find it difficult to engage in leisure activities quietly?

    And how was that during childhood (in play activities)?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 5 - Are you often 'on the go' or do you often act as if 'driven by a motor'?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 6 - Do you often talk excessively?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 7 - Do you often blurt out an answer before questions have been completed?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 8 - Do you often find it difficult to await your turn?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • H/I 9 - Do you often interrupt or intrude on others?

    And how was that during childhood?
  • Examples Adulthood*
  • Symptom Present?
  • Examples Childhood*
  • Symptom Present?

  • Criterion B

  • Have you always had these symptoms of attention deficit and/or hyperactivity/impulsivity?*

  • Criterion C

    In which areas do you have / have you had problems with these symptoms?

  • ADULTHOOD:

  • WORK / EDUCATION*

  • CHILDHOOD:

  • EDUCATION*

  • ADULTHOOD:

  • RELATIONSHIPS / FAMILY*

  • CHILDHOOD:

  • FAMILY*

  • ADULTHOOD:

  • SOCIAL CONTACTS*

  • CHILDHOOD

  • SOCIAL CONTACTS*

  • ADULTHOOD:

  • FREE TIME / HOBBIES*

  • CHILDHOOD

  • FREE TIME / HOBBIES*

  • ADULTHOOD:

  • SELF-CONFIDENCE / SELF-IMAGE*

  • CHILDHOOD

  • SELF-CONFIDENCE / SELF-IMAGE*

  • Part 3: Impairment on account of the symptoms

    Criterion B
  • Have you always had these symptoms of attention deficit and/or hyperactivity/impulsivity?*

  • Criterion D:

    In this section we ask that you explain in more detail (using personal examples) how your experience of ADHD symptoms has interfered in the quality of your social / academic / occupational life.

  • Thank you for completing this form!

    You may now click 'submit'!

  • We would like to express our sincere gratitude for completing this form in preparation for your upcoming ADHD Direct appointment. We value your contribution immensely and eagerly anticipate reviewing the details you have provided to ensure a thorough evaluation.

    If you have any additional concerns or questions prior to your appointment, please do not hesitate to contact us. We look forward to meeting you soon!

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