Name of Observer:______________________ Person Observed:______________________

Date:_________________Check the box that best describes this person's behavior over the past six months

Not at all

Just a little

Often

Very Often

Inattention Symptoms

1.

fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

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2.

has difficulty sustaining attention in tasks

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3.

does not seem to listen when spoken to directly

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4.

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

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5.

has difficulty organizing tasks and activities

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6.

avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

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7.

loses things necessary for tasks or activities

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8.

is easily distracted by extraneous stimuli

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9.

is forgetful in daily activities

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Hyperactivity Symptoms

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10.

fidgets with hands or feet or squirms when seated

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11.

leaves seat in situations in which staying seated is expected

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12.

appears to be restless

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13.

has difficulty playing or engaging in leisure activities quietly

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14.

is “on the go” or often acts as if “driven by a motor”

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15.

talks excessively

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Impulsivity SymptomsImpulsivity Sympto

a

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16.

blurts out answers before questions have been completed

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17.

has difficulty awaiting his or her turn

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18.

interrupts or intrudes on others (e.g., butts into conversations or activities)

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Approximately when did you first notice these behaviors in this person?

Do these symptoms impair this person’s functioning in two or more settings? (Yes, No, Don’t Know)

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

                                       Scoring Instructions for the Adult ADHD Symptom Checklist
To meet DSM-IV criteria for ADHD in childhood, a child or adolescent must have at least 6 responses of "Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive items (1-9) or 9 hyperactive-impulsive items (10-18), or both. However, these thresholds may be lowered for adults. The clinician may consider ADHD as a possible diagnosis if even 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.