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*

MonthDayYear
Date
Date of Birth*

DayMonthYear
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*

	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 .*

	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*

	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)

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Having problems with family
2. Having problems with partner/ spouse
3. Relying on others to do things for you
4. Causing fighting in the family
5. Makes it hard for the family to have fun together
6. Problems taking care of your family
7. Problems balancing your needs against those in the family
8. Problems losing control with family

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Problems performing required duties
2. Problems with getting your work done efficiently
3. Problems with your supervisor
4. Problems with keeping a job
5. Getting fired from work
6. Problems working in a team
7. Problems with your attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Poor performance evaluations

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Problems taking notes
2. Problems completing assignments
3. Problems getting your work done efficiently
4. Problems with teachers
5. Problems with school administrators
6. Problems meeting minimum requirements to stay in school
7. Problems with attendance
8. Problems with being late
9. Problems with working to your potential
10. Problems with inconsistent grades

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Excessive or inappropriate use of internet, video games or TV
2. Problems keeping an acceptable appearance
3. Problems getting ready to leave the house
4. Problems getting to bed
5. Problems with nutrition
6. Problems with sex
7. Problems with sleeping
8. Getting hurt or injured
9. Avoiding exercise
10. Problems keeping regular appointments with doctor/dentist
11. Problems keeping up with household chores
12. Problems managing money

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Feeling bad about yourself
2. Feeling frustrated with yourself
3. Feeling discouraged
4. Not feeling happy with your life
5. Feeling incompetent

Depression, Anxiety, Stress, Scale (DASS - 21)

General Health Questionnaire

1. General Physical health

WEISS Functional Impairment Rating Scale - Self Report (WFIRS-S)

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Getting into arguments
2. Trouble cooperating
3. Trouble getting along with people
4. Problems having fun with other people
5. Problems participating in hobbies
6. Problems making friends
7. Problems keeping friends
8. Saying inappropriate things
9. Complaints from neighbours

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Aggressive driving
2. Doing other things while driving
3. Road rage
4. Breaking or damaging things
5. Doing things that are illegal
6. Being involved with the police
7. Smoking cigarettes
8. Smoking marijuana
9. Drinking alcohol
10. Taking "street" drugs
11. Sex without protection (birth control, condom)
12. Sexually inappropriate behaviour
13. Being physically aggressive
14. Being verbally aggressive