Inattention

Do you often fail to give close attention to details, or make careless mistakes in schoolwork, work, or other activities?

Do you often have difficulty sustaining attention in tasks or play activities?

Do you often seem not to listen when spoken to directly?

Do you often not follow through on instructions and fail to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)?

Do you often have difficulty organizing tasks and activities?

Do you often avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)?

Do you often lose things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile phones)?

Are you often easily distracted by extraneous stimuli?

Are you often forgetful in daily activities?

Hyperactivity and Impulsivity

Do you often fidget with or tap your hands or feet, or squirm in your seat?

Do you often leave your seat in situations when remaining seated is expected?

Do you often feel restless or fidgety, or have difficulty sitting still in situations where remaining seated is expected?

Are you often unable to play or engage in leisure activities quietly?

Are you often "on the go," acting as if "driven by a motor"?

Do you often talk excessively?

Do you often blurt out an answer before a question has been completed?

Do you often have difficulty waiting your turn?

Do you often interrupt or intrude on others (e.g., butting into conversations or games)?

Age of Onset

At what age did you FIRST notice significant problems with attention, focus, organization, or hyperactivity/impulsivity?

Thinking back to elementary school (ages 5-12), did you experience difficulties with attention, hyperactivity, or impulsivity?

Did your childhood report cards or parent-teacher conferences mention concerns about: (Select all that apply)

Multiple Settings

In which settings do you experience these ADHD-related difficulties? (Select all that apply)

At WORK or SCHOOL, how often do these symptoms cause noticeable problems?

At HOME, how often do these symptoms cause noticeable problems?

In SOCIAL SITUATIONS, how often do these symptoms cause noticeable problems?

Functional Impairment

How much do these symptoms interfere with your quality of life?

Work/School Performance

Problems completing tasks (homework, paperwork, projects) on time

Not working up to your potential

Problems getting work done efficiently

Daily Functioning

Problems managing money (spending, planning, budgeting)

Problems keeping home organized and tidy

Trouble getting places on time

Losing or misplacing things

Relationships

Problems getting along with significant other (spouse, partner)

Problems getting along with friends

Having a hard time understanding other people's point of view

Self-Esteem & Mental Health

Feeling bad or not pleased with yourself

Not feeling confident

Feeling stressed or overwhelmed

Mental Health Screening

Over the past 2 weeks, how often have you been bothered by the following?

Depression Screening (PHQ-9)

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling/staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself in some way

Anxiety Screening (GAD-7)

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Additional Medical History

Have you ever been diagnosed with or treated for any of these? (Select all that apply)

Are you currently taking any psychiatric medications?

Do you have a family history of ADHD?