Attention type - English

בס''ד
ADHD Type
Name*
Last Name*
Filled by*
Date*

MonthDayYear
Date
Code
Birthdate*

MonthDayYear
Date
Age
Mail
The completed form will be sent to this email address.
Fecha2*

MonthDayYear
Date
edad dias
To be able to help in the best possible way, please take the necessary time to fill out this questionnaire in the most accurate way possible. Of course, all details will be kept strictly confidential.
A) Main difficulties
In what areas is he/she strong?
Where do you see the main difficulties today?
Are there areas in wich it is especially important for you to advance (language, friendship, motor skills, acting, etc.)?

B) Checklist
Dear parent!

Filling out the questionnaire accurately is extremely important for the success of the treatment.

The answers are concerning his condition without the effect of an ADHD drug.

Note! The numbers from 1 to 4 refer to the frequency of the difficulty and not the level of difficulty.
Notes:

0 = Never / Not applicable

1 = Rarely

2 = Occasionally

3 = Frequently

4 = Very Frequently

Please specify how often these issues occur:

	0	1	2	3	4	Comments
1. Easily distracted.
2. Difficulty sustaining attention span for most tasks, homework, play, school or work.
3. Doesn't seem to hear when talking to him/her (e.g. not listening to what parent is saying, seemingly ignoring them).
4. Difficulty (delay, following through, procrastinating) in carrying out tasks or instructions or difficulty finishing tasks to completion.
5. Difficulty maintaining order and organization of his environment and belongings (room, table, bag, closet, drawer, etc.)
6. Has trouble with time (i.e. frequently late or hurried, tasks take longer than expected, projects or homework are "last minute" or turned in late).
7. Tendency to lose things.
8. Makes careless mistakes, poor attention to detail.
9. Forgetful.
10. Restless, unusually active.
11. Trouble sitting still, fidgety, constant motion (hands, feet, body).
12. Noisy, has trouble being quiet.
13. Acts as if "driven by a motor"
14. Talks excessively.
15. Impulsive (doesn't think through comments or actions before they are said or done).
16. Has a hard time waiting for his turn.
17. IInterrupts others, butts into others' conversations or games.
18. Difficulty delaying gratification.
19. Excessive or senseless worrying.
20. Super organized, everything has to be in its place and order.
21. Oppositional, argumentative.
22. Strong tendency to get locked into negative thoughts, having the same thought/phrase over and over again.
23. Tendency toward obsessive/compulsive behavior.
24. Intense dislike for change, reacts with frustration to unplanned scenarios.
25. Difficulty adapting to new situations.
26. Tendency to hold grudges..
27. Difficulty shifting attention from one subject to another.
28. Difficulty finding alternative solutions.
29. Tendency to cling to one's own opinion and not listen to others.
30. He becomes stuck in his course of action and has difficulty adapting even if it is against his own benefit.
31. Not aware that worries too much.
32.Periods of extreme irritability or explosive with little provocation.
33. Misinterprets comments or situations as negative when they are not.
34. Irritability tends to build, then explodes, then recedes, often tired after a rage.
35. Periods of spaciness or confusion.
36. Periods of panic and/or fear for no specific reason.
37. Imagines visual changes like seeing shadows or objects changing shape.
38. Frequent periods of deja vu (the feeling of having experienced the same situation in the past even if it never happened).
39. Hypersensitivity or mild paranoia.
40. Headaches or abdominal pain of uncertain origin.
41. History of a head injury (0=no damage, 4=severe damage).
42. Dark thoughts, may involve suicidal or homicidal thoughts.
43. Periods of forgetfulness or memory problems.
44. Impatient.
45. Dejected, disheartened.
46. Tends to be negative.
47. Low energy / apathy / passivity.
48. Frequent irritability.
49. Tendency to be socially isolated.
50. Frequent feelings of hopelessness, helplessness, or excessive guilt.
51. Does not enjoy things that are usually considered fun.
52. Sleep difficulties (too much or too little).
53. Chronic low self-esteem.
54. Angry or aggressive.
55. Sensitive to noise, light, clothes or touch.
56. Frequent or cyclic mood changes (highs and lows).
57. Inflexible, rigid in the way of thinking.
58. Difficulty accepting a request that goes against his will, even if it is asked several times.
59. Periods of insensitive, mean, or nasty behavior to his surroundings.
60. Periods of increased speech, talkativeness.
61. Periods of increased impulsivity (act before thought)..
62. Unpredictable behavior.
63. Grandiose thinking (overly confident or arrogant attitude).
64. Looks anxious or fearful.
65. Predicts the worst
66. Freezes in social situations.
67. Tension that manifests itself physically: headaches or great muscle tension.
68. Conflict avoidant even when needed.
69. Fear of being judged.
70. Excessive motivation.

Comments
(Based on Dr. Amen Brain Test Questionnaire).
Should be Empty:

ADHD Type

A) Main difficulties

B) Checklist

Dear parent!