James Fitzgerald Therapy, PLLC James Fitzgerald, MS, NCC, AAP, Psychotherapist Strengthening Your Conscious Self © 2022 Intake Screening Assessment Adult ADHD Self Report Scale Please enable JavaScript in your browser to complete this form.Information about youYour user ID is the way I identify who is filling out this survey. The information is securely transmitted, private and confidential. Please answer the questions as honestly as you are comfortable with. LayoutUser ID (number)DateScreening QuestionsCompleting this self-report scale questionnaire should not be considered your formal assessment for diagnosing ADHD. A diagnosis can only be made after a thorough multiple part assessment which should include the person's family, or people who know the person, and the person's primary care physician or prescriber.How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?NeverRarelySometimesOftenVery OftenHow often do you leave your seat in meetings or other situations in which you are expected to remain seated?NeverRarelySometimesOftenVery OftenHow often do you have difficulty unwinding and relaxing when you have time to yourself?NeverRarelySometimesOftenVery OftenWhen you're in a conversation, how often do you find yourself finishing the sentence of the people you are talking to before they can finish it themselves?NeverRarelySometimesOftenVery OftenHow often do you put things off until the last minute?NeverRarelySometimesOftenVery OftenHow often do you admit to doing a task you were asked to do, even when you have not completed that task?NeverRarelySometimesOftenVery OftenHow often do you depend on others to keep your life in order and attend to details?NeverRarelySometimesOftenVery OftenHow often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?NeverRarelySometimesOftenVery Often How often do you have difficulty getting things in order when you have to do a task that requires organization?NeverRarelySometimesOftenVery OftenHow often do you have problems remembering appointments or obligations?NeverRarelySometimesOftenVery OftenHow often do you have problems remembering important details or fulfilling responsibilities, like paying bills?NeverRarelySometimesOftenVery OftenWhen you have a task that requires a lot of thought, how often do you avoid or delay getting started? NeverRarelySometimesOftenVery OftenHow often do you feel restless or fidgety? NeverRarelySometimesOftenVery OftenHow often do you fidget or squirm with your hands or feet when you have to sit down for a long time?NeverRarelySometimesOftenVery OftenHow often do you feel overly active and compelled to do things, like you were driven by a motor? NeverRarelySometimesOftenVery OftenHow often do you make careless mistakes when you have to work on a boring or difficult project? NeverRarelySometimesOftenVery OftenHow often do you have difficulty keeping your attention when you are doing boring or repetitive work?NeverRarelySometimesOftenVery OftenHow often do you misplace or have difficulty finding things at home or at work? NeverRarelySometimesOftenVery OftenHow often are you distracted by activity or noise around you?NeverRarelySometimesOftenVery OftenHow often do you find yourself talking too much when you are in social situations?NeverRarelySometimesOftenVery OftenHow often do you have difficulty waiting your turn in situations when turn taking is required? NeverRarelySometimesOftenVery OftenHow often do you interrupt others when they are busy? NeverRarelySometimesOftenVery OftenHow often do you get frustrated, annoyed, or irritated when your plans or goals get sidetracked or sabotaged?NeverRarelySometimesOftenVery OftenHow often do you get overwhelmed and exhausted when you are overstimulated?NeverRarelySometimesOftenVery OftenSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link