Adult ADHD Symptoms

Please fill out the following form to help us understand your condition.

First Name

Email Address

Last Name

Date of Birth

1. Fail to give close attention to details or make careless mistakes in my work or other activities

Never or rarely

Sometimes

Often

Very often

2. Difficulty sustaining my attention in tasks or fun activities

Never or rarely

Sometimes

Often

Very often

3. Don’t listen when spoken to directly

Never or rarely

Sometimes

Often

Very often

4. Don’t follow through on instructions and fail to finish work or chores.

Never or rarely

Sometimes

Often

Very often

5. Have difficulty organizing tasks and activities

Never or rarely

Sometimes

Often

Very often

6. Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort

Never or rarely

Sometimes

Often

Very often

7. Lose things necessary for tasks or activities

Never or rarely

Sometimes

Often

Very often

8. Easily distracted by extraneous stimuli or irrelevant thoughts.

Never or rarely

Sometimes

Often

Very often

9. Forgetful in daily activities

Never or rarely

Sometimes

Often

Very often

10. Fidget with hands or feet or squirm in seat

Never or rarely

Sometimes

Often

Very often

11. Leave my seat in meetings or in other situations in which remaining seated is expected

Never or rarely

Sometimes

Often

Very often

12. Shift around excessively or feel restless or hemmed in

Never or rarely

Sometimes

Often

Very often

13. Have difficulty engaging in leisure activities quietly (feel uncomfortable, or am loud or noisy)

Never or rarely

Sometimes

Often

Very often

Thanks for submitting!

Adult ADHD Symptoms

(Form 2)

Please fill out the following form to help us understand your condition.

First Name

Email Address

Last Name

Date of Birth

1. I fail to give close attention to details or make careless mistakes in my work or other activities

Never or rarely

Sometimes

Often

Very often

2. I have difficulty sustaining my attention in tasks or fun activities

Never or rarely

Sometimes

Often

Very often

3. Don’t listen when spoken to directly

Never or rarely

Sometimes

Often

Very often

4. Don’t follow through on instructions and fail to finish work or chores.

Never or rarely

Sometimes

Often

Very often

5. Have difficulty organizing tasks and activities

Never or rarely

Sometimes

Often

Very often

6. Avoid, dislike, or am reluctant to engage in tasks that require sustained mental effort

Never or rarely

Sometimes

Often

Very often

7. Lose things necessary for tasks or activities

Never or rarely

Sometimes

Often

Very often

8. Easily distracted by extraneous stimuli or irrelevant thoughts.

Never or rarely

Sometimes

Often

Very often

9. Forgetful in daily activities

Never or rarely

Sometimes

Often

Very often

10. Fidget with hands or feet or squirm in seat

Never or rarely

Sometimes

Often

Very often

11. Leave my seat in meetings or in other situations in which remaining seated is expected

Never or rarely

Sometimes

Often

Very often

12. Shift around excessively or feel restless or hemmed in

Never or rarely

Sometimes

Often

Very often

13. Have difficulty engaging in leisure activities quietly (feel uncomfortable, or am loud or noisy)

Never or rarely

Sometimes

Often

Very often

14. I am “on the go” or act as if “driven by a motor” (or I feel like I have to be busy or always doing something)

Never or rarely

Sometimes

Often

Very often

15. Talk excessively (in social situations)

Never or rarely

Sometimes

Often

Very often

16. Blurt out answers before questions have been completed, complete others’ sentences, or jump the gun

Never or rarely

Sometimes

Often

Very often

17. Have difficulty awaiting my turn

Never or rarely

Sometimes

Often

Very often

18. Interrupt or intrude on others (butt into conversations or activities without permission or take over what others are doing)

Never or rarely

Sometimes

Often

Very often

19. Prone to daydreaming when I should have been concentrating on something or working

Never or rarely

Sometimes

Often

Very often

20. Have trouble staying alert or awake in boring situations

Never or rarely

Sometimes

Often

Very often

21. Easily confused

Never or rarely

Sometimes

Often

Very often

22. Easily bored

Never or rarely

Sometimes

Often

Very often

23. Spacey or “in a fog”

Never or rarely

Sometimes

Often

Very often

24. Lethargic, more tired than others

Never or rarely

Sometimes

Often

Very often

25. Underactive or have less energy than others

Never or rarely

Sometimes

Often

Very often

26. Slow moving

Never or rarely

Sometimes

Often

Very often

27. I don’t seem to process information as quickly or as accurately as others.

Never or rarely

Sometimes

Often

Very often

If you have experienced any of the symptoms above either often or very often, what age were you when they first began?

Please provide examples of any of your current difficulties experienced at home, if any

Please provide examples of any of your current difficulties experienced at work, if any

Please provide examples of any of your current difficulties experienced with social relationships if any

Adult ADHD Symptoms

Adult ADHD Symptoms

Adult ADHD Symptoms

Adult ADHD Symptoms

Adult ADHD Symptoms (Form 2)

Adult ADHD Symptoms

(Form 2)