ADHD RS IV with Adult Prompts

Family Care Clinic | D. Blayne Laws, M.D. | Office 972-875-6700 | Fax 972-875-6790

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Date

ADHD-RS-IV with Adult Prompts

The ADHD-RS-IV with Adult Prompts is an 18-item scale based on the DSM-IV- TR criteria for ADHD that provides a rating of the severity of symptoms. The adult prompts serve as a guide to explore more fully the extent and severity of ADHD symptoms and create a framework to ascertain impairment.

None - 0 | Mild - 1 | Moderate - 2 | Sever - 3

1. Carelessness

Do you make a lot of mistakes (in school or work)?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is this because you're careless?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you rush through work or activities?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have trouble with detailed work?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you not check your work?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do people complain that you're careless?

0 - None 1- Mild 2 - Moderate 3 - Severe

Are you messy or sloppy?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is your desk or workspace so messy that you have difficulty finding things?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Question 1.

0 - None 1- Mild 2 - Moderate 3 - Severe

2. Difficulty sustaining attention in activities

Do you have trouble paying attention when:

Watching movies, reading, or attending lectures?

0 - None 1- Mild 2 - Moderate 3 - Severe

On fun activities such as sports or board games?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it hard for you to keep your mind on school or work?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have unusual trouble staying focused on boring or repetitive tasks?

0 - None 1- Mild 2 - Moderate 3 - Severe

Does it take a lot longer than it should to complete tasks because you can't keep your mind on the task?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it even harder for you than some others you know?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have trouble remembering what you read and do you need to re-read the same passage several times?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 2

0 - None 1- Mild 2 - Moderate 3 - Severe

3. Doesn't listen

Do people (spouse, boss, colleagues or friends) complain that you don't seem to listen or respond (or daydream) when spoken to or when asked to do tasks? A lot?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do people have to repeat directions?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you find that you miss the key parts of conversation because of drifting off in your own thoughts? Does this cause a problem?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 3

0 - None 1- Mild 2 - Moderate 3 - Severe

4. No follow through

Do you have (trouble finishing things (such as work or chores)?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you often leave things half done and start another project?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need consequences (such as deadlines) to finish?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have trouble following instructions (especially complex, multistep instructions) that have to be done in a certain order with different steps?)

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need to write down instructions, otherwise you will forget them?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 4

0 - None 1- Mild 2 - Moderate 3 - Severe

5. Can't organize

Do you have trouble organizing tasks into ordered steps?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it hard prioritizing work and chores?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need others to plan for you?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have trouble with time management? Does it cause problems?

0 - None 1- Mild 2 - Moderate 3 - Severe

Does difficulty in planning lead to procrastination and putting off tasks until the last moment possible?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 5

0 - None 1- Mild 2 - Moderate 3 - Severe

6. Avoids/dislikes tasks requiring sustained mental effort

Do you avoid tasks (work, chores, reading, board games) that are challenging or lengthy because it's hard to stay focused on these things for a long time?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have to force yourself to do these tasks?

0 - None 1- Mild 2 - Moderate 3 - Severe

How hard is it?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you procrastinate and put off tasks until the last moment possible?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 6

0 - None 1- Mild 2 - Moderate 3 - Severe

7. Loses important items

Do you lose things (eg, important work papers, keys, wallet, coats, etc) A lot? More than others?

0 - None 1- Mild 2 - Moderate 3 - Severe

Are you constantly looking for important items?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you get into trouble for this (at work or at home)?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need to put items (eg, glasses, wallet, keys) in the same place each time, otherwise you will lose them?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 7

0 - None 1- Mild 2 - Moderate 3 - Severe

8. Easily distracted

Are you ever very easily distracted by events around you such as noise (conversation, TV, radio), movement, or clutter?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need relative isolation to get work done?

0 - None 1- Mild 2 - Moderate 3 - Severe

Can almost anything get your mind off of what you are doing, such as work, chores, or if you're talking to someone?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it hard to get back to a task once you stop?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 8

0 - None 1- Mild 2 - Moderate 3 - Severe

9. Forgetful in daily activities

Do you forget a lot of things in your daily routine? Like chores, work, appointments or obligations?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you forget to bring things to work, such as work materials or assignments due that day?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you need to write regular reminders to yourself to do most activities or tasks, otherwise you will forget?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 9

0 - None 1- Mild 2 - Moderate 3 - Severe

10. Squirms and fidgets

Can you sit still or are you always moving your hands or feet or fidgeting in your chair?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you tap your pencil or your feet? A lot? Do people notice?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you regularly play with your hair or clothing?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you consciously resist fidgeting or squirming?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 10

0 - None 1- Mild 2 - Moderate 3 - Severe

11. Can't stay seated

Do you have trouble staying in your seat? At work? In class? At home (eg, watching TV. eating dinner)? In church or temple?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you choose to walk around rather than sit?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you have to force yourself to remain seated?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it difficult for you to sit through a long meeting or lecture?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you try to avoid going to functions that require you to sit still for long periods of time?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 11

0 - None 1- Mild 2 - Moderate 3 - Severe

12. Runs/climbs excessively

Are you physically restless?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you feel restless inside? A lot?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you feel more agitated when you cannot exercise on an almost daily basis?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 12

0 - None 1- Mild 2 - Moderate 3 - Severe

13. Can't play/work quietly

Do you have a hard time playing/working quietly?

0 - None 1- Mild 2 - Moderate 3 - Severe

During leisure activity (non-structured time, such as reading a book, listening to music, playing a board game), are you agitated or dysphoric?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you always need to be busy after work or while on vacation?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 13

0 - None 1- Mild 2 - Moderate 3 - Severe

14. On the go, "driven by a motor"

Is it hard for you to slow down?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you feel like you (often) have a lot of energy and that you always have to be moving, are you always "on the go"?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you feel like you're driven by a motor?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you feel unable to relax?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 14

0 - None 1- Mild 2 - Moderate 3 - Severe

15- Talks excessively

Do you talk a lot? All the time? More than other people?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do people complain about your talking? Is it a problem?

0 - None 1- Mild 2 - Moderate 3 - Severe

Are you often louder than the people you are talking to?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 15

0 - None 1- Mild 2 - Moderate 3 - Severe

16. Blurts out answers

Do you give answers to questions before someone finishes asking?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you say things before it is your turn?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you say things that don't fit into the conversation?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you say things that don't fit into the conversation?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 16

0 - None 1- Mild 2 - Moderate 3 - Severe

17. Can't wait for turn

Is it hard for you to wait your turn (in conversation, in lines, while driving)?

0 - None 1- Mild 2 - Moderate 3 - Severe

Are you frequently frustrated with delays? Does it cause problems?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you put a great deal of effort into planning to not be in situations where you might have to wait?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 17

0 - None 1- Mild 2 - Moderate 3 - Severe

18. Intrudes/interrupts others

Do you talk when others are talking, without waiting until you are acknowledged?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you butt into others' conversations before being invited?

0 - None 1- Mild 2 - Moderate 3 - Severe

Do you interrupt others' activities?

0 - None 1- Mild 2 - Moderate 3 - Severe

Is it hard for you to wait to get your point across in conversations or at meetings?

0 - None 1- Mild 2 - Moderate 3 - Severe

Highest score for Section 18

0 - None 1- Mild 2 - Moderate 3 - Severe

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