Eclipse Mental Health Services

Patient Name:

Date:

Place a ✔️ next to each statement that describes you

SI:

1. Often fails to give close attention to detail or makes mistake

2. Often has difficulty susta ining attention in tasks or activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish schoolwork or workplace duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort

7. Often loses things necessary for tasks or activities

8. Is easily distracted by extraneous stimuli

9. Is often forgetful in daily activities

SH:

10. Often fidgets with or taps hands and feet, or squirms in seat

11. Often leaves seat in situations when remaining seated is expected

12. Often runs and climbs in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restle ss)

13. Often unable to play or engage in leisure activities quietly

14. Is often "on the go", acting as if "driven by a motor"

15. Often talks excessively

16. Often blurts out answers before a question has been completed

17. Often has difficulty waiting for their turn

18. Often interrupts or intrudes on others

1. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

0 1 2 3 4 5

2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

0 1 2 3 4 5

3. How often do you have difficulty unwinding and relaxing when you have time to yourself?

0 1 2 3 4 5

4. When you're in a conversation, how often do you find yourself finishing the sentences of people you are talking to before they finish them themselves.

0 1 2

5. How often do you put things off until the last minute?

0 1 2 3 4

6. How often do you depend on others to keep your life in order and attend-to details?

0 1 2 3

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