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Chester ADHD Self Report Scale Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown using the scale never, rarely, sometimes, often, very often.

As you answer each question, select an answer that best describes how you have felt and conducted yourself over the post 6 months.

The form is strictly confidential and the site uses SSL, so all data is encrypted.

ADHD Self-Report Form

Please complete all sections

Patient Name *

Form Section

Part A

1) How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *Select One

2) How often do you have difficulty getting things in order when you have to do a task that requires organisation? *Select One

3) How often do you have problems remembering appointments or obligations? *Select One

4) When you have a task that requires a lot of thought, how often do you avoid or delay getting started? *Select One

5) How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? *Select One

6) How often do you feel overly active and compelled to do things, like you were driven by a motor? *Select One

Form Section

Part B

7) How often do you make careless mistakes when you have to work on a boring or difficult project? *Select One

8) How often do you have difficulty keeping your attention when you are doing boring or repetitive work? *Select One

9) How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? *Select One

10) How often do you misplace or have difficulty finding things at home or at work? *Select One

11) How often are you distracted by activity or noise around you? *Select One

12) How often do you leave your seat in meetings or other situations in which you are expected to remain seated? *Select One

13) How often do you feel restless or fidgety? *Select One

14) How often do you have difficulty unwinding and relaxing when you have time to yourself? *Select One

15) How often do you find yourself talking too much when you are in social situations? *Select One

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? *Select One

17) How often do you have difficulty waiting your turn in situations when turn taking is required? *Select One

18) How often do you interrupt others when they are busy? *Select One