ADHD Symptom Screening Form
Answer 6 questions about your experiences over the past 6 months and review the scoring guidance at the end.
Please note: this form is not currently submitted through a HIPAA-compliant system, so confidentiality of your responses cannot be fully guaranteed in transit and storage.
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Date of Completion
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Over the past 6 months, how often have you experienced each of the following?
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Rows
Never
Rarely
Sometimes
Often
Very Often
Trouble wrapping up final details of a project
Difficulty getting things in order for tasks requiring organization
Problems remembering appointments or obligations
Avoiding or delaying tasks requiring a lot of thought
Fidgeting or squirming when sitting for a long time
Feeling overly active, like driven by a motor
Scoring: Never=0, Rarely=1, Sometimes=2, Often=3, Very Often=4. Add the six scores together for a total out of 24. Higher scores suggest ADHD symptoms are more strongly indicated. This is a guide for treatment planning only, not a diagnostic tool.
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