ADHD Self-Assessment

ADHD Self-Assessment

(For the Individual)
Patient Name:*
Date of Birth:*

MonthDayYear
Date
Date of Assessment:*

MonthDayYear
Date
This questionnaire is designed to help you assess ADHD-related symptoms in your daily life. Please answer each question based on your experiences over the past few weeks. There are no right or wrong answers - just respond as accurately as possible.
Section 1: Attention & Organization
1. How often do you make careless mistakes in your work, schoolwork, or daily tasks?*

NeverSometimesOftenVery Often
2. How often do you have difficulty sustaining attention in tasks or conversations?*

NeverSometimesOftenVery Often
3. How often do you find it difficult to listen when spoken to directly?*

NeverSometimesOftenVery Often
4. How often do you struggle to complete tasks that require sustained mental effort?*

NeverSometimesOftenVery Often
5. How often do you struggle with organization (e.g., keeping track of responsibilities, planning tasks)?*

NeverSometimesOftenVery Often
6. How often do you avoid or procrastinate on tasks that require mental effort?*

NeverSometimesOftenVery Often
7. How often do you misplace important things (e.g., keys, phone, documents)?*

NeverSometimesOftenVery Often
8. How often do you forget to do things, even when they are important?*

NeverSometimesOftenVery Often
9. How often do you get distracted by your surroundings or unrelated thoughts?*

NeverSometimesOftenVery Often
If known, at what age did these attention-related difficulties first become noticeable?
If any of these challenges significantly impact your life, you can provide an example here (optional):
Section 2: Hyperactivity & Impulsivity
10. How often do you fidget, tap your hands or feet, or have trouble staying still?*

NeverSometimesOftenVery Often
11. How often do you leave your seat in situations where staying seated is expected?*

NeverSometimesOftenVery Often
12. How often do you feel restless or as if you’re always on the go?*

NeverSometimesOftenVery Often
13. How often do you talk excessively or interrupt others?*

NeverSometimesOftenVery Often
14. How often do you blurt out answers or struggle to wait your turn in conversations?*

NeverSometimesOftenVery Often
15. How often do you have difficulty waiting in lines or for your turn?*

NeverSometimesOftenVery Often
16. How often do you intrude into others’ conversations or activities?*

NeverSometimesOftenVery Often
If known, at what age did these hyperactivity or impulsivity difficulties first become noticeable?
If any of these challenges significantly impact your life, you can provide an example here (optional):
Section 3: Impact on Daily Life
In your own words, how do these symptoms affect:
Your daily routine and responsibilities?
Your work or school performance?
Your relationships with others?
Total Inattentive Score (9 Questions):
Total Hyperactive/Impulsivity Score (7 Questions):
Should be Empty:

ADHD Self-Assessment

Section 1: Attention & Organization

Section 2: Hyperactivity & Impulsivity

Section 3: Impact on Daily Life