Adult Adhd Self-Report Scale (Asrs-V 1.1) Symptom Checklist Template
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1Adult ADHD Self-Report Scale (ASRS-v 1.1) Symptom Checklist
Patient Name
Today’s Date
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 doctor to discuss the findings.
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 tum in situations when
tum taking is required?
18.
How often do you interrupt others when they are busy?
Part B
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