Adult ADHD Seif-Report Scale (ASRS-vI.I) Symptom Checklist

Patient First Name

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Patient Last Name

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Today’s Date

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Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

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2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

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3. How often do you have problems remembering appointments or obligations?

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4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

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5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

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6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

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7. How often do you make careless mistakes when you have to work on a boring or difficult project?

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8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

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9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

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10. How often do you misplace or have difficulty finding things at home or at work?

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11. How often are you distracted by activity or noise around you?

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12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

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13. How often do you feel restless or fidgety?

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14. How often do you have difficulty unwinding and relaxing when you have time to yourself?

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15. How often do you find yourself talking too much when you are in social situations?

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16. When you're 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?

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17. How Often do you have difficulty waiting your turn in situation when turn-taking is required?

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18. How often do you interrupt others when they are busy?

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