You can always press Enter⏎ to continue
ADHD in Relationships Questionnaire
Hi there, please fill out and submit this form.
12
Questions
START
1
1. How severe do you perceive your ADHD to be on a scale of 1-10, where 1 is not very severe and 10 is extremely severe?
Previous
Next
Submit
Press
Enter
2
2. Is your ADHD medicated?
YES
NO
Previous
Next
Submit
Press
Enter
3
3. What is your most frustrating ADHD trait?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
4
4. In what ways does ADHD impact your relationship in positive ways?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
5
5. In what ways does ADHD affect your relationship in negative ways?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
6
6. What are some strategies you use to manage your ADHD in your everyday life (other than medication)?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
7
7. What are some strategies you use to manage your ADHD in your relationship?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
8
8. With which traits would you like more support in managing your ADHD?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
9
9. Are there any particular triggers for your ADHD traits? (ie. that make your ADHD harder to manage?)
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
10
10. In what ways would you love your partner to help you with your ADHD?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
11
Contact Details
If you would like to be informed of future "Support for ADHD in Relationships" resources available from Rachel Jakobi, please enter your
name
and
email address
below
First Name
Last Name
Previous
Next
Submit
Press
Enter
12
example@example.com
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
12
See All
Go Back
Submit