Adult ADHD-RS-IV with Adult Prompts

Patient Name

Date

Please select the appropriate number and place in the box below. The questions are examples that will prompt your answer. Use this tool when you are on your medication.

1. Carelessness Do you make a lot of mistakes (in school or work)? Is this because you are careless? Do you rush through work or activities? Do you have trouble with detailed work? Are you messy or sloppy and do you have difficulty finding things?

None Mild

Moderate

Severe

2. Difficulty sustaining attention in activities Do you have trouble paying attention when watching movies, reading or attending lectures, or fun activities such as sports or board games? Is it hard to keep your mind on school or work? Does it take a lot longer than it should to complete tasks because you can't keep your mind on the task? Is it harder for you than some others you know? Do you have trouble remembering what you read and do you need to re-read the same passage several times?

None Mild

Moderate

Severe

3. Doesn't Listen Do people (spouse, boss, colleagues, friends) complain that you don't seem to listen or respond (or daydream) when spoken to or when asked to do tasks? A lot? Do people have to repeat directions? Do you find that you miss the key parts of a conversation because of drifting off in you own thoughts?

None Mild

Moderate

Severe

4. No follow through Do you have trouble finishing things (such as work or chores)? Do you often leave things half done and start another project? Do you need consequences such as deadlines to finish? Do you have trouble following instructions (especially complex, multistep instructions that have to be done in a certain order with different steps)? do you need to write down instructions, otherwise you will forget them?

None Mild

Moderate

Severe

5. Can't organize Do you have trouble organizing tasks into ordered steps? Is it hard prioritizing work and chores? Do you need others to plan for you? Do you have trouble with time management? Does difficulty in planning lead to procrastination and putting off tasks until the last moment possible?

None Mild

Moderate

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? Do you have to force yourself to do these tasks? Do you procrastinate and put off tasks until the last moment possible?

None Mild

Moderate

Severe

7. Loses important items Do you lose things (e.g.. Important work papers, keys, wallet, coats, etc.)? A lot? More than others? Are you constantly looking for important items? Do you get into trouble for this (at work or at home)? Do you need to put items (glasses, wallet, keys) in the same place each time, otherwise you will lose them?

None Mild

Moderate

Severe

8. Easily distractible Are you ever very easily distracted by events around you such as noise conversation, TV or radio, movement or clutter? Do you need relative isolation to get your work done? Can almost anything get your mind off of what you are doing, such as work, chores or if you are talking to someone? Is it hard to get back to a task once you stop?

None Mild

Moderate

Severe

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

None Mild

Moderate

Severe

10. Squirms and fidgets Can you sit still or are you always moving your hands or feet, or fidgeting in your chair? Do you tap your pencil or your feet? A lot? Do people notice? Do you regularly play with your hair or clothing? Do you consciously resist fidgeting or squirming?

None Mild

Moderate

Severe

11. Can't stay seated? Do you have trouble staying in your seat? (At work, In class or at home? Watching TV or eating dinner? Do you choose to walk around rather than sit? Is it difficult for you to sit through a long meeting or lecture? Do you try to avoid going to functions that require you to sit still for long periods of time?

None Mild

Moderate

Severe

12. Runs/climbs excessively Are you physically restless? Do you feel restless inside? A lot? Do you feel more agitated when you cannot exercise on an almost daily basis?

None Mild

Moderate

Severe

13. Can't play/work quietly Do you have a hard time playing/working quietly? During leisure activity (nonstructured times or on your won such as reading a book, listening to music, playing a board game), are you agitated or dysphoric?

None Mild

Moderate

Severe

14. On the go, "driven by a motor" Is it hard for you to slow down? Do you feel like you (often) have a lot of energy and that you always have to be moving, are always "on the go"? Do you feel like you're driven by a motor? Do you feel unable to relax?

None Mild

Moderate

Severe

15. Talks excessively Do you talk a lot? All the time? More than other people? Do people complain about your talking? Are you often louder than the people you are talking to?

None Mild

Moderate

Severe

16. Blurts out answers Do you give answers to questions before someone finishes asking? Do you say things before it is your turn? Do you say things that don't fit into the conversation? Do you do things without thinking? A lot?

None Mild

Moderate

Severe

17. Can't wait for turn Is it hard for you to wait your turn (in conversation, in lines, while driving)? Are you frequently frustrated with delays? Does it cause problems?

None Mild

Moderate

Severe

18. Intrudes/interrupts others Do you talk when others are talking, without waiting until you are acknowledged? Do you butt into others' conversations before being invited? Do you interrupt others' activities? Is it hard for you to wait to get your point across in conversations or at meetings?

None Mild

Moderate

Severe

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