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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Name *

Date Completed *

Month Day Year

Date of Birth *

Month Day Year

Email *

example@example.com

Please answer the questions below, rating yourself on each of the criteria . As you answer each
question, select the single choice that best describes how you have felt and conducted yourself
over the past 6 months. This form can be be submitted and can be discussed during your next
appointment with Dr. Flett *
Very
Never Rarely Sometimes Often
Often
1. How often do you have trouble wrapping up the final details
of a project, once thechallenging parts have been done?

2. How often do you have difficulty getting things in order when

you have to do a task thatrequires 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 gettingstarted?

5. How often do you fidget or squirm with your hands or feet

when you have to sit down for along time?

6. How often do you feel overly active and compelled to do

things, like you were driven by amotor?

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 7. How often do you make careless mistakes when you have to
work on a boring or difficultproject?

8. How often do you have difficulty keeping your attention

when you are doing boring orrepetitive work?

9. How often do you have difficulty concentrating on what

people say to you, even when theyare 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 in other

situations in which you areexpected to stay 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 thepeople you are talking to,
before they can finish it 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?

Dr. JOHN FLETTjohnflett@mweb.co.zaMBChB(Pret), FCP(Paed)(SA), MRCP(Paed)(UK)Specialist PaediatricianHillcrest Private Hospital Rooms

031 7688122471 Kassier Road, Assagay, 3610 Fax 0866 857093Suite 8 Practice No: 3206181 Email: hillcrest@mweb.co.za Website:
www.healthtalk.co.zawww.knowsomemore.o.za The information contained in this email is confidential and may be subject to legal privilege. The
content of this email, which may include one or more attachments, is strictly confidential, and is intended solely for the use of the named
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any action in reliance on it.If you have received this email in error, please email the sender by replying to this message and to permanently delete
it and all attachments from your computer. All reasonable precautions have been taken to ensure that no viruses are present in this email and
the company cannot accept responsibility for any loss or damage arising from the use of this email or attachments.

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