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ADD and ADHD Free Treatment Screening
Name or Nickname (optional)
Email
Phone
Please answer the questions below, rating yourself on a scale of 1 through 5 on each of the criteria as shown. Answer each question in a way that best describes how you have felt and conducted yourself in the past 6 months.
Section A -
INATTENTION
. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have difficulty getting things in order when you have to do a task that requires organization?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have problems remembering appointments or obligations?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you make careless mistakes when you have to work on a boring or difficult project?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you misplace or have difficulty finding things at home or at work?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often are you distracted by activity or noise around you?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
Total Points of: Section A - Inattention
Section B -
HYPERACTIVITY
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you feel overly active and compelled to do things, like you were driven by a motor?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you feel restless or fidgety?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have difficulty unwinding and relaxing when you have time to yourself?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you find yourself talking to much when you are in social situations?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
When you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you have difficulty waiting your turn in situations when turn taking is required?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
How often do you interrupt others when they are busy?
1 (Never)
2 (Rarely)
3 (Sometime)
4 (Often)
5 (Always)
Total Points of: Section B - Hyperactivity
Total Points of: Section A and Section B
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