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ASRS-ADHD-self-report-scale-2 2

This document is an Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist that contains 18 questions for patients to rate themselves on symptoms of inattention and hyperactivity over the past 6 months. Patients are asked to place an X in boxes using a Likert scale to indicate how often they experience each symptom. The checklist is given to healthcare professionals to discuss symptoms of ADHD during an appointment.

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Alexys Archie
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718 views2 pages

ASRS-ADHD-self-report-scale-2 2

This document is an Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist that contains 18 questions for patients to rate themselves on symptoms of inattention and hyperactivity over the past 6 months. Patients are asked to place an X in boxes using a Likert scale to indicate how often they experience each symptom. The checklist is given to healthcare professionals to discuss symptoms of ADHD during an appointment.

Uploaded by

Alexys Archie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Adult ADHD Self-Report Scale (ASRS-v1.

1) Symptom Checklist
Patient Name Today’s Date

V
Please answer the questions below, rating yourself on each of the criteria shown using the So er
scale on the right side of the page. As you answer each question, place an X in the box that Ra m y
Ne Oft
best describes how you have felt and conducted yourself over the past 6 months. Please rel eti O
ver en
give this completed checklist to your healthcare professional to discuss during today’s y m ft
appointment. es e
n

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?

Registered Address: Trewalder Chapel, Trewalder, Cornwall, PL33 9ET - co. no. OC372755
www.psychiatry-uk.com Tel: (+44) 33 0124 1980 | Fax: (+44) 20 3744 2961
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

Registered Address: Trewalder Chapel, Trewalder, Cornwall, PL33 9ET - co. no. OC372755
www.psychiatry-uk.com Tel: (+44) 33 0124 1980 | Fax: (+44) 20 3744 2961

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