ADD Prescreening Questionnaire

 

 


Adult ADHD Symptom Checklist-Self Report

 

Name: ______________________________________________                          Date: ____________________
Check the box that best describes your behavior over the past six months.

 

 

Not at all

Just a little

Often

Very Often

1.

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

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2.

have difficulty sustaining attention in tasks

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3.

do not seem to listen when spoken to directly

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4.

do not follow through on instructions and fail to finish schoolwork, responsibilities, or duties in the workplace (not due to oppositional behavior or failure to understand)

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5.

have difficulty organizing tasks and activities

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6.

avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort

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7.

lose things necessary for tasks or activities

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8.

am easily distracted by extraneous stimuli

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9.

am forgetful in daily activities

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10.

fidget with hands or feet or squirm when seated

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11.

leave seat in situations in which staying seated is expected

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12.

feel restless

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13.

have difficulty engaging in leisure activities quietly

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14.

am "on the go" or often act as if "driven by a motor"

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15.

talk excessively

,

,

,

,

16.

blurt out answers before questions have been completed

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17.

have difficulty awaiting my turn

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18.

interrupt or intrude on others (e.g., butt into conversations or activities)

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Approximately when did you first notice the behaviors that occur often or very often?    

Do these symptoms impair your functioning in two or more settings? (Yes, No, DK)     

Where is their impairment? Family? School? Work? Social? (list all)    

Scoring Instructions for the Adult ADHD Symptom Checklist
To meet DSM-IV criteria for ADHD in childhood, a child must have at least 6 responses of "Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive items (1-9) or the 9 hyperactive-impulsive items (10-18), or both. These thresholds may be lowered for adults. ADHD may be a possible diagnosis if only four or five symptoms are scored 2 or 3 in either one or both domains. In addition, symptoms must have occurred in childhood, they must impair the individual's functioning in two or more settings, and they must not be primarily due to any other factors or conditions. Depending on the domains affected, ADHD, predominantly inattentive type; ADHD, predominantly hyperactive-impulsive type; or ADHD, combined type may be considered. Using a rating scale such as this, however, is not sufficient in and of itself to diagnose ADHD. Other sources of information should be considered and an appropriate health professional should be consulted.

My score indicates I may have Adult ADD.   Now what?  

My score indicates I probably don't have ADD but I'm not convinced that I don't. 

 

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