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

This document is an Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist for a patient. It contains 18 questions for the patient to rate themselves on how often they experience common ADHD symptoms over the past 6 months using a scale from never to often. Examples of symptoms addressed include having trouble finishing tasks, being distracted, forgetfulness, fidgeting, feeling restless, interrupting others, and having difficulty waiting their turn. The patient is asked to complete the checklist to discuss with their healthcare provider at their appointment.

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Tom
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948 views2 pages

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

This document is an Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist for a patient. It contains 18 questions for the patient to rate themselves on how often they experience common ADHD symptoms over the past 6 months using a scale from never to often. Examples of symptoms addressed include having trouble finishing tasks, being distracted, forgetfulness, fidgeting, feeling restless, interrupting others, and having difficulty waiting their turn. The patient is asked to complete the checklist to discuss with their healthcare provider at their appointment.

Uploaded by

Tom
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as 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
S
Please answer the questions below, rating yourself on each of the criteria o
shown using the scale on the right side of the page. As you answer each Ne Ra m
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
ve rel et Often
checklist to your healthcare professional to discuss during today’s r y i
appointment. m
es
⦁ How often do you have trouble wrapping up the final details of a
project, once the challenging parts have been done?
⦁ How often do you have difficulty getting things in order when
you have to do a task that requires organization?
⦁ How often do you have problems remembering appointments or
obligations?
⦁ When you have a task that requires a lot of thought, how often
do you avoid or delay getting started?
⦁ How often do you fidget or squirm with your hands or feet when
you have to sit down for a long time?
⦁ How often do you feel overly active and compelled to do things,
like you were driven by a motor?

⦁ How often do you make careless mistakes when you have to


work on a boring or difficult project?
⦁ How often do you have difficulty keeping your attention when
you are doing boring or repetitive work?
⦁ How often do you have difficulty concentrating on what people
say to you, even when they are speaking to you directly?
⦁ How often do you misplace or have difficulty finding things at
home or at work?
⦁ How often are you distracted by activity or noise around you?

⦁ How often do you leave your seat in meetings or other situations


in which you are expected to remain seated?
⦁ How often do you feel restless or fidgety?
⦁ How often do you have difficulty unwinding and relaxing when
you have time to yourself?
⦁ How often do you find yourself talking too much when you are in
social situations?
⦁ 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?

1
⦁ How often do you have difficulty waiting your turn in situations
when turn taking is required?

⦁ How often do you interrupt others when they are busy?

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