1. Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

1. Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Patient Name*

Date Completed*

Date

Date of Birth*

Date

Email*

example@example.com

Part A: Please answer the questions below, rating yourself on each of the criteria. As you answer each question, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and can be discussed during your next appointment with Dr. Paterson*

Rows	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B - Please answer the questions below, rating yourself on each of the criteria .*

Rows	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?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you are expected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
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 it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Part C*

Rows	Yes	No
Did you experience any of these 18 symptoms at least "Often" or "Very often"?
If so, did your symptoms impair your functioning at school?
If so, did your symptoms impair your functioning at home?
If so, did your symptoms impair your functioning at work?
If so, did your symptoms impair your functioning in your social relationships?

Age when these symptoms began:*

Part A Q 1-6 (Admin use only)

Part B: Questions 7-18 (Admin use only)*

Total for Part A + Part B (Admin use only)