Adult ADHD Self-Report Scale (ASRS-v1.

1) Symptom Checklist
Instructions
The questions on the back page are designed to stimulate dialogue between you and your patients and to help
confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD).

Description: The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria.
Six of the eighteen questions were found to be the most predictive of symptoms consistent with
ADHD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the
Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions.

Instructions:

Symptoms

1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X
in the box that most closely represents the frequency of occurrence of each of the symptoms.

2. Score Part A. If four or more marks appear in the darkly shaded boxes within Part A then the
patient has symptoms highly consistent with ADHD in adults and further investigation is
warranted.

3. The frequency scores on Part B provide additional cues and can serve as further probes into the
patient’s symptoms. Pay particular attention to marks appearing in the dark shaded boxes. The
frequency-based response is more sensitive with certain questions. No total score or diagnostic
likelihood is utilized for the twelve questions. It has been found that the six questions in Part A
are the most predictive of the disorder and are best for use as a screening instrument.

Impairments

1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment
associated with the symptom.

2. Consider work/school, social and family settings.

3. Symptom frequency is often associated with symptom severity, therefore the Symptom
Checklist may also aid in the assessment of impairments. If your patients have frequent
symptoms, you may want to ask them to describe how these problems have affected the ability
to work, take care of things at home, or get along with other people such as their
spouse/significant other.

History

1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have
ADHD need not have been formally diagnosed in childhood. In evaluating a patient’s history,
look for evidence of early-appearing and long-standing problems with attention or self-control.
Some significant symptoms should have been present in childhood, but full symptomology is not
necessary.
 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Patient Name Today’s Date
Please answer the questions below, rating yourself on each of the criteria shown using the

Very Often
Sometimes
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

Rarely
Never

Often
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?

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 you
were driven by a motor?
Part A
7. How often do you make careless mistakes when you have to work on a boring or
difficult project?

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

9. How often do you have difficulty concentrating on what people say to you,
even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?

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

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

13. How often do you feel restless or fidgety?

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

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

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?
17. How often do you have difficulty waiting your turn in situations when
turn taking is required?

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

Part B
Wender Utah Rating Scale for the Attention Deficit Hyperactivity
Disorder

Overview:

The Wender Utah Rating Scale can be used to assess adults for Attention Deficit
Hyperactivity Disorder with a subset of 25 questions associated with that
diagnosis.

Wender Utah Rating Scale

x 61 questions answered by the adult patient recalling his or her childhood

As a child I was (or had): not at all mildly moder- quite very
or very ately a bit much
slightly
1 active restless always on the 0 1 2 3 4
go
2 afraid of things 0 1 2 3 4
3 concentration problems 0 1 2 3 4
easily distracted
4 anxious worrying 0 1 2 3 4
5 nervous fidgety 0 1 2 3 4
6 inattentive daydreaming 0 1 2 3 4
7 hot- or short-tempered low 0 1 2 3 4
boiling point
8 shy sensitive 0 1 2 3 4
9 temper outbursts tantrums 0 1 2 3 4
10 trouble with stick-to-it- 0 1 2 3 4
tiveness not following
through. failing to finish
things started
11 stubborn strong-willed 0 1 2 3 4
12 sad or blue depressed 0 1 2 3 4
unhappy
13 incautious. dare-devilish 0 1 2 3 4
involved in pranks
14 not getting a kick out of 0 1 2 3 4
things dissatisfied with life
15 disobedient with parents 0 1 2 3 4
rebellious sassy
16 low opinion of myself 0 1 2 3 4
17 irritable 0 1 2 3 4
 not at all mildly moder- quite very
or very ately a bit much
slightly
18 outgoing friendly enjoyed 0 1 2 3 4
company of people
19 sloppy disorganized 0 1 2 3 4
20 moody ups and downs 0 1 2 3 4
21 angry 0 1 2 3 4
22 friends popular 0 1 2 3 4
23 well-organized tidy neat 0 1 2 3 4
24 acting without thinking 0 1 2 3 4
impulsive
25 tendency to be immature 0 1 2 3 4
26 guilty feelings regretful 0 1 2 3 4
27 losing control of myself 0 1 2 3 4
28 tendency to be or act 0 1 2 3 4
irrational
29 unpopular with other 0 1 2 3 4
children didn't keep friends
for long didn't get along with
other children
30 poorly coordinated did not 0 1 2 3 4
participate in sports
31 afraid of losing control of self 0 1 2 3 4
32 well-coordinated picked first 0 1 2 3 4
in games
33 tomboyish (for women only) 0 1 2 3 4
34 running away from home 0 1 2 3 4
35 getting into fights 0 1 2 3 4
36 teasing other children 0 1 2 3 4
37 leader bossy 0 1 2 3 4
38 difficulty getting awake 0 1 2 3 4
39 follower led around too 0 1 2 3 4
much
40 trouble seeing things from 0 1 2 3 4
someone else's point of view
41 trouble with authorities 0 1 2 3 4
trouble with school visits to
principal's office
42 trouble with police booked 0 1 2 3 4
convicted
 Medical problems as a not at all mildly moder- quite very
child or very ately a bit much
slightly
43 headaches 0 1 2 3 4
44 stomachaches 0 1 2 3 4
45 constipation 0 1 2 3 4
46 diarrhea 0 1 2 3 4
47 food allergies 0 1 2 3 4
48 other allergies 0 1 2 3 4
49 bedwetting 0 1 2 3 4
As a child in school I was not at all mildly moder- quite very
(or had) or very ately a bit much
slightly
50 overall a good student fast 0 1 2 3 4
51 overall a poor student slow 0 1 2 3 4
learner
52 slow in learning to read 0 1 2 3 4
53 slow reader 0 1 2 3 4
54 trouble reversing letters 0 1 2 3 4
55 problems with spelling 0 1 2 3 4
56 trouble with mathematics or 0 1 2 3 4
numbers
57 bad handwriting 0 1 2 3 4
58 able to read pretty well but 0 1 2 3 4
never really enjoyed reading
59 not achieving up to potential 0 1 2 3 4
60 repeating grades 0 1 2 3 4
61 suspended or expelled 0 1 2 3 4
 Questions Associated with ADHD This page
should not be
x 25 of the questions were associated with ADHD as follows: given or shown
to the patient.
As a child I was (or had):
3 concentration problems easily distracted
4 anxious worrying
5 nervous fidgety
6 inattentive daydreaming
7 hot- or short-tempered low boiling point
9 temper outbursts tantrums
10 trouble with stick-to-it-tiveness not following through. failing to finish things
started
11 stubborn strong-willed
12 sad or blue depressed unhappy
15 disobedient with parents rebellious sassy
16 low opinion of myself
17 irritable
20 moody ups and downs
21 angry
24 acting without thinking impulsive
25 tendency to be immature
26 guilty feelings regretful
27 losing control of myself
28 tendency to be or act irrational
29 unpopular with other children didn't keep friends for long didn't get along with
other children
40 trouble seeing things from someone else's point of view
41 trouble with authorities trouble with school visits to principal's office
As a child in school I was (or had)
51 overall a poor student slow learner
56 trouble with mathematics or numbers
59 not achieving up to potential

Wender Utah rating scale subscore = ________(sum of 25 questions associated with ADHD)

Interpretation:

x minimum score for the 25 questions is 0

References:

Ward MF Wender PH Reimherr FW. The Wender Utah Rating Scale: An aid in the retrospective
diagnosis of childhood Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 1993; 150:
885-890.