Clinical Screening

Adult ADHD Self-Report Scale (ASRS-v1.1) — Part A

Please answer based on your life over the last 6 months. 0 = never, 4 = very often. Shaded responses help your physician assess ADHD symptoms.

Patient Information

First Name *

Last Name *

Date of Birth *

Score: 0/24

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

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

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

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

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

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

Signature (typed name) *

Date *