Adult ADHD Self Forms 🧠✨

This form is for the patient to complete personally. Please send separate collateral forms to other people who know you well.

Patient full name

First NameLast Name

Date of birth

Date

Email

example@example.com

Today's date

Date

Wender Utah Rating Scale-25 (WURS-25)

Rows	Not at all or very slightly	Mildly	Moderately	Quite a bit	Very much
As a child, did you have trouble concentrating or paying attention?
As a child, were you hyperactive or restless?
As a child, were you disorganized or messy?
As a child, did you have mood swings?
As a child, were you nervous, tense, or anxious?
As a child, did you have temper outbursts or anger problems?
As a child, were you stubborn or strong-willed?
As a child, did you have trouble completing tasks?
As a child, were you easily distracted?
As a child, did you have low self-esteem?
As a child, did you feel sad or blue?
As a child, did you have trouble with peers?
As a child, were you forgetful?
As a child, did you daydream?
As a child, were you fidgety?
As a child, did you have trouble following directions?
As a child, did you act without thinking?
As a child, were you noisy?
As a child, did you have trouble getting along with authority figures?
As a child, were you socially withdrawn?
As a child, did you have trouble learning in school?
As a child, did you have trouble finishing things you started?
As a child, did you have a short attention span?
As a child, were you emotional or sensitive?
As a child, did you have trouble controlling your behavior?

Attention

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Attention to details or makes careless mistakes
Holding attention or remaining focused
Listening or mind seems elsewhere
Instructions or finishing work
Organizing (e.g. time, messy, deadlines)
Avoids or dislikes activities requiring effort
Loses or misplaces things
Easily distracted
Forgetful (e.g. chores, bills, appointments)

Hyperactivity and Impulsivity

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Fidgets or squirms
Trouble staying seated
Runs about or feels restless inside
Loud or difficulty being quiet
Often on the go
Talks too much
Blurts out comments
Dislikes waiting (e.g. taking turns or in line)
Interrupts or intrudes on others (e.g. butting in)

Oppositional

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Loses temper
Easily annoyed
Angry and resentful
Argues
Defiant
Deliberately annoys other people
Blames other people rather than themselves
Spiteful

Development and Learning

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Wetting (after age 5)
Soiling (after age 4)
Reading
Spelling
Math
Writing

Autism Spectrum

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Difficulty with talking back and forth
Unusual eye contact or body language
Speech is odd (monotone, unusual words)
Restricted, fixed, intense interests
Odd, repetitive movements (e.g. flapping)
Does not easily chit chat

Motor Disorders

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Repetitive noises (e.g. sniffing, throat clearing)
Repetitive movements (blinking, shrugging)
Clumsy

Psychosis

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Hearing voices that are not there
Seeing things that are not there
Scrambled thinking
Paranoia (feeling people are against you)

Depression

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Sad or depressed most of the day
Lack of interest or pleasure most of the day
Weight loss, weight gain or change in appetite
Difficulty sleeping or sleeping too much
Agitated
Slowed down
Feels worthless
Tired, no energy
Hopeless, pessimistic
Withdrawal from usual interests/people
Decrease in concentration

Mood Regulation

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Distinct periods of intense excitement
Distinct periods of inflated self-esteem, grandiose
Distinct periods of increased energy
Distinct periods of decreased need for sleep
Distinct periods of racing thoughts or speech
Irritable behaviour that is out of character
Rage attacks, anger outbursts, hostility

Suicide

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Suicidal thoughts
Suicide attempt(s) or a plan

Anxiety

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Intense fears (e.g. heights, crowds, spiders)
Fear of social situations or performing
Panic attacks
Fear of leaving the house or public transportation
Worrying and/or anxious most days
Nervous, can't relax
Obsessive thoughts (e.g. germs, perfectionism)
Compulsive rituals (e.g. checking, hand washing)
Hair pulling, nail biting or skin picking
Preoccupation with physical complaints
Chronic pain

Stress Related Disorders

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Physical abuse
Sexual abuse
Neglect
Other severe trauma

PTSD

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Flashbacks or nightmares
Avoidance
Intrusive thoughts of traumatic events

Sleep

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Trouble falling asleep or staying asleep
Excessive daytime sleepiness
Snoring or stops breathing during sleep

Eating

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Distorted body image
Underweight
Binge eating
Overweight
Eating too little or refusing to eat

Conduct

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Verbal aggression
Physical aggression
Used a weapon against people (stones, sticks etc.)
Cruel to animals
Physically cruel to people
Stealing or shoplifting
Deliberately sets fires
Deliberately destroys property
Frequent lying
Lack of remorse or guilt
Lack of empathy or concern for others

Substance Use

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Misuse of prescription drugs
Alcohol more than 14 drinks per week or 4 drinks at once
Smoking or tobacco use
Marijuana
Other street drugs
Excessive over the counter medications
Excessive caffeine (colas, coffee, tea, pills)

Addictions

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Gambling
Excessive internet, gaming or screen time
Other addiction

Personality

Rows	None (0)	Mild (1)	Moderate (2)	Severe (3)	N/A
Self-destructive
Stormy, conflicted relationships
Self-injurious behaviour (e.g. cutting)
Low self-esteem
Manipulative
Self-centered
Arrogant
Suspicious
Deceitful with no remorse
Breaking the law or antisocial behaviour
Tends to be a loner

A. Family

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Family relationships
Family responsibilities
Parenting or caregiving responsibilities
Conflict at home

B. Work

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Job performance
Meeting deadlines
Organizational skills at work
Workplace relationships

C. School

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Class attendance or participation
Completing assignments
Studying or concentrating
Academic performance

D. Life Skills

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Managing time
Keeping track of belongings
Daily routines and responsibilities
Managing finances

E. Self-Concept

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Self-esteem
Feeling capable or successful
Frustration with yourself
Confidence in handling responsibilities

F. Social

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Making or keeping friends
Social interactions
Listening in conversations
Social conflicts

G. Risk

Rows	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	N/A
Impulsive behavior
Accidents or injuries
Risky decisions
Getting into trouble

Internal scoring summary

WURS-25 total score is captured automatically in the section data.
WSR-II section scores are captured automatically by domain, with N/A excluded from means.
WFIRS-S section scores are captured automatically by domain, with N/A excluded from means.

Please complete this section yourself. Answer using how you have been functioning recently. For items that mention school, think work, home, daily tasks, meetings, deadlines, appointments, and current functioning. For any childhood references, answer based on behavior before age 12.

ADHD symptoms

Rows	Never	Rarely	Sometimes	Often	Very Often
Often fails to give close attention to details or makes careless mistakes
Often has difficulty sustaining attention in tasks
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish work
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort
Often loses things necessary for tasks and activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Often fidgets with hands or feet or squirms in seat
Often leaves seat in situations when remaining seated is expected
Often feels restless or fidgety
Often has difficulty engaging in leisure activities quietly
Is often on the go as if driven by a motor
Often talks excessively
Often blurts out an answer before a question has been completed
Often has difficulty waiting turn
Often interrupts or intrudes on others

Use this section to describe your current symptoms, any ADHD medication you are taking, how well it is working, and any side effects or concerns.

Current ADHD medication or treatment

Medication response and current symptom control

Rows	Much worse	Worse	No change	Somewhat better	Much better
Focus and attention
Organization and task completion
Restlessness or hyperactivity
Impulsivity
Emotional regulation
Day-to-day functioning

Side effects you are experiencing

Additional notes or concerns

Adult ADHD Self Forms 🧠✨

Patient Information

Wender Utah Rating Scale-25 (WURS-25)

Weiss Symptom Record II (WSR-II)

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

ADHD Rating Scale (ADHD-RS)

CADDRA Medication and Symptom Form