ADD/ADHD Self Assessment Form
http://webdoc.nyumc.org/nyumc/files/psych/attachments/psych_adhd_checklist.pdf
The best way to use this is to print the form, give one to a family member (that you trust), print one out for yourself, then when you are done, compare.
If you struggle with 4 or more of Part A symptoms look to part B for additional clues. Bring both questionnaires to the doctor. Then…read up on ADD/ADHD in adults, women, anything you can get your hands on. Maybe read up BEFORE you go to the doctor.
Patient Name
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? Never Rarely Sometimes Often Very Often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization? Never Rarely Sometimes Often Very Often
3. How often do you have problems remembering appointments or obligations? Never Rarely Sometimes Often Very Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? Never Rarely Sometimes Often Very Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? Never Rarely Sometimes Often Very Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Never Rarely Sometimes Often Very Often
7. How often do you make careless mistakes when you have to work on a boring or difficult project? Never Rarely Sometimes Often Very Often
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? Never Rarely Sometimes Often Very Often
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? Never Rarely Sometimes Often Very Often
10. How often do you misplace or have difficulty finding things at home or at work? Never Rarely Sometimes Often Very Often
11. How often are you distracted by activity or noise around you? Never Rarely Sometimes Often Very Often
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? Never Rarely Sometimes Often Very Often
13. How often do you feel restless or fidgety? Never Rarely Sometimes Often Very Often
14. How often do you have difficulty unwinding and relaxing when you have time to yourself? Never Rarely Sometimes Often Very Often
15. How often do you find yourself talking too much when you are in social situations? Never Rarely Sometimes Often Very Often
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? Never Rarely Sometimes Often Very Often
17. How often do you have difficulty waiting your turn in situations when turn taking is required? Never Rarely Sometimes Often Very Often
18. How often do you interrupt others when they are busy? Never Rarely Sometimes Often Very Often
TOP 10 signs of ADHD or 33…
TOP Ten Manifestations of Adult ADHD
Cover of Top Ten (Book 1)
- Disorganized
- Reckless Driving/Traffic Accidents
The Reckless Driver (Photo credit: Wikipedia)
- Marital/Relationship Problems
- Extreme Distractibility
- Poor Listening Skills
- Restlessness, Problems Relaxing
Restless_Comp1.jpg (Photo credit: remytherestless)
- Procrastination, Problems starting a Task
- Chronic Lateness
The Late, Late, Late Show (Photo credit: Wikipedia)
- Angry outbursts (living on Anger Street)
Straßenschild Anger - Bahnhofstraße, Erfurt (Photo credit: Wikipedia)
- Prioritizing Issues and then there are more:
- Losing track of thoughts/ideas in the middle of tasks
- Missing details or making careless mistakes
- Inability to complete assignments work/school
- Forgetfulness
Forgetfulness helps the enemy. Don't let it happen here - NARA - 535247 (Photo credit: Wikipedia)
- Difficulty following instructions
- Restless, constantly shifting in chair, tapping feet or pencil playing or tugging at hair or clothing and unable to stop.
- Impulsive, childish i.e. Can’t stand waiting in line, constant interrupting, blurt out inappropriate comments, trouble anticipating consequences of their actions, change jobs frequently or have trouble keeping one, one task done well, the other done poorly, late, or incomplete, breezes through some things but can’t others,
The Madman's Return (Photo credit: Wikipedia)
- Self-medicates with caffeine, cigarettes even street drugs
- Trouble staying in the present
- Hypersensitive…lights too bright, sounds too loud, touches irritating/annoying, smells too strong
Pressure Sensitive (Photo credit: Wikipedia)
- Social strangeness, ie. Life of the party or avoids social interactions, seems callous and insensitive to others often
Cover of Life of the Party
- Short tempered, easily frustrated,
- No sense of time…overestimates or underestimates the amount of time it takes to complete any task, plans are vague or nonexistent
- Often extremely intelligent person that does “stupid” things
- Trouble focusing, spaces out often if not interested and can hyper focus if they are interested
Spaced Out Bunny (Photo credit: Wikipedia)
- Often have developed strange seemingly complex strategies to compensate their inabilities
- Agitated
- Laugh themselves silly…then cry
Cry Now, Laugh Later (Photo credit: Wikipedia)
- Easily overwhelmed
- Impulsive and Compulsive
Careless "Borrowing" is Sabotage - NARA - 514033 (Photo credit: Wikipedia)
- Barely aware of how their behaviour affects others
- Insomniac or excessive sleeper
Insomnia smiley (Photo credit: Wikipedia)
- No boundaries, often invades other’s personal space and last but certainly not least…. FORGETFULNESS. HOW MANY OF THESE SIGNS APPLY TO YOU???
