Questionnaire #1: Instructions: As you answer each question, indicate which option best describes how you have felt and conducted yourself OVER THE PAST 6 MONTHS.
Response Options:
Never = 0 Rarely = 1 Sometimes = 2 Often = 3 Very Often = 4
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How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2
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How often do you have difficulty getting things in order when you have to do a task that requires organization? 3
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How often do you have problems remembering appointments or obligations? 2
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When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 4
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How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 4
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How often do you feel overly active and compelled to do things, like you were driven by a motor? 4
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How often do you make careless mistakes when you have to work on a boring or difficult project? 4
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How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 4
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How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 2
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How often do you misplace or have difficulty finding things at home or at work? 1
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How often are you distracted by activity or noise around you? 2
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How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 0
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How often do you feel restless or fidgety? 3
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How often do you have difficulty unwinding and relaxing when you have time to yourself? 4
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How often do you find yourself talking too much when you are in social situations? 0
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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? 2
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How often do you have difficulty waiting your turn in situations when turn taking is required? 0
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How often do you interrupt others when they are busy? 2
Questionnaire #2:
Instructions: This questionnaire asks your experiences AS A CHILD.
Response Options:
Not at all or very slightly = 0 Mildly = 1 Moderately = 2 Quite a bit = 3 Very much = 4
AS A CHILD I WAS (OR HAD):
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active restless always on the go 2
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afraid of things 1
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concentration problems easily distracted 1
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anxious worrying 2
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nervous fidgety 2
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inattentive daydreaming 1
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hot- or short-tempered low boiling point 0
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shy sensitive 2
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temper outbursts tantrums 0
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trouble with stick-to-it-tiveness not following through. failing to finish things started 2
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stubborn strong-willed 4
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sad or blue depressed unhappy 1
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incautious. dare-devilish involved in pranks 0
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not getting a kick out of things dissatisfied with life 0
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disobedient with parents rebellious sassy 2
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low opinion of myself 1
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irritable 1
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outgoing friendly enjoyed company of people 1
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sloppy disorganized 3
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moody ups and downs 2
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angry 1
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friends popular 2
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well-organized tidy neat 0
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acting without thinking impulsive 1
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tendency to be immature 0
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guilty feelings regretful 1
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losing control of myself 0
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tendency to be or act irrational 0
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unpopular with other children didn’t keep friends for long didn’t get along with other children 0
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poorly coordinated did not participate in sports 0
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afraid of losing control of self 0
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well-coordinated picked first in games 1
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tomboyish (for women only)
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running away from home 1
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getting into fights 0
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teasing other children 1
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leader bossy 2
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difficulty getting awake 0
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follower led around too much 0
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trouble seeing things from someone else’s point of view 2
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trouble with authorities trouble with school visits to principal’s office 0
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trouble with police booked convicted 0
MEDICAL PROBLEMS AS A CHILD
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headaches 3
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stomachaches 1
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constipation 1
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diarrhea 1
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food allergies 1
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other allergies 1
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bedwetting 1
AS A CHILD IN SCHOOL I WAS (OR HAD)
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overall a good student fast 4
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overall a poor student slow learner 0
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slow in learning to read 0
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slow reader 0
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trouble reversing letters 0
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problems with spelling 0
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trouble with mathematics or numbers 0
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bad handwriting 4
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able to read pretty well but never really enjoyed reading 0
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not achieving up to potential 1
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repeating grades 0
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suspended or expelled 0