Adult Self-Report Scale (ASRS) Symptom Checklist

Universal Pediatric Associates, PC | 422 Worcester Street, Suite 105 Wellesley, MA 02481 | (781) 235-9737

Please correct the errors described below.

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, circle the correct number that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.

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