Instructions: Indicate the degree to which you have experienced the following problems recently (during the last week) as well as during your childhood (younger than age 7) for your childhood responses take into account your own recall and what you have learned from what you have learned from a parent or teachers.

		Not At All	Mild	Moderate	Severe
1. Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.	Adult	0	1	2	3
	Child	0	1	2	3
2. Has difficulty sustaining attention in tasks or activities.	Adult	0	1	2	3
	Child	0	1	2	3
3. Does not seem to listen when spoken to directly.	Adult	0	1	2	3
	Child	0	1	2	3
4. Does not follow through on instructions and fails to finish schoolwork, work assignments, chores, duties.	Adult	0	1	2	3
	Child	0	1	2	3
5. Has difficulty organizing tasks and activities.	Adult	0	1	2	3
	Child	0	1	2	3
6. Avoids, dislikes or is reluctant to engage in tacks that require sustained mental effort (i.e. procrastinates).	Adult	0	1	2	3
	Child	0	1	2	3
7. Loses things necessary for tasks or activities (e.g. keys, books, tools).	Adult	0	1	2	3
	Child	0	1	2	3
8. Easily distracted.	Adult	0	1	2	3
	Child	0	1	2	3
9. Forgetful in daily activities.	Adult	0	1	2	3
	Child	0	1	2	3
10. Fidgets with hands or feet or squirms in seat.	Adult	0	1	2	3
	Child	0	1	2	3
11. Leaves seat in situations in which remaining seated is expected.	Adult	0	1	2	3
	Child	0	1	2	3
12. Moves about excessively (e.g. can't sit still) or often feels restless.	Adult	0	1	2	3
	Child	0	1	2	3
13. Has difficult playing or engaging in leisure activities quietly.	Adult	0	1	2	3
	Child	0	1	2	3
14. "On the go" or acts as if "driven by a motor."	Adult	0	1	2	3
	Child	0	1	2	3
15. Talks excessively.	Adult	0	1	2	3
	Child	0	1	2	3
16. Blurts our answers before questions have been completed.	Adult	0	1	2	3
	Child	0	1	2	3
17. Has difficulty awaiting turn (e.g. line ups, traffic lights, games).	Adult	0	1	2	3
	Child	0	1	2	3
18. Interrupts or intrudes on other (e.g. butts into conversation or games).	Adult	0	1	2	3
	Child	0	1	2	3
19. How old were you when problems with attention, impulsiveness, or hyperactivity first begin to occur?

If you answered moderate or severe to five or more of the questions, you might consider talking with a psychologist or physician about being evaluated for ADHD.