ADHD CHECKLIST

For each item below, circle the response that best describes this patient.

0=Not at all; 1=Only a little; 2=Often; 3=Very often

Symptoms of inattention

1. Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., neglects or misses details, work is inaccurate). 0 1 2 3

2. Has difficulty sustaining attention in tasks or play activities (e.g., has difficulty staying focused during lectures; conversations; or long readings). 0 1 2 3

3. Does not seem to listen when spoken to directly (e.g., mind seems to be elsewhere, even in the absence of any obvious distractions). 0 1 2 3

4. Does not follow through on instructions and fails to finish schoolwork, chores, or workplace duties (e.g., starts tasks but quickly loses focus and is easily distracted). 0 1 2 3

5. Has difficulty organizing tasks and activities (e.g., has difficulty managing sequential tasks; has difficulty keeping materials and belongings in order; is messy, disorganized with work; has poor time management; fails to meet deadlines). 0 1 2 3

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, filling out forms, proofreading long papers). 0 1 2 3

7. Loses things needed for tasks or activities (e.g., school supplies, pencils, books, tools, wallets, keys, documents, eyeglasses, cell phone). 0 1 2 3

8. Is easily distracted by extraneous stimuli (for older adolescents and adults, may include thoughts). 0 1 2 3

9. is forgetful in daily activities (e.g., doing chores, running errands; for older teens and adults, returning phone calls, paying bills, making appointments). 0 1 2 3

Hyperactive Symptoms

10. fidgets or taps hands or feet or squirms in seat 0 1 2 3

11. leaves seat in situations where it is inappropriate (NOTE: In teens or adults, this may be limited to feelings of restlessness). 0 1 2 3

12. unable to play or engage in leisure activities quietly 0 1 2 3

13. has difficulty playing or engaging in leisure activities quietly 0 1 2 3

14. is “on the move” or acts as if “driven by a motor” (e.g., is unable or uncomfortable sitting still for long periods of time in restaurants, meetings; may be described by others as fidgety) 0 1 2 3

15. talks excessively 0 1 2 3

Impulsive Symptoms

16. blurts out an answer before the question is finished (e.g., finishes people’s sentences; cannot wait for their turn in conversation). 0 1 2 3

17. has difficulty waiting their turn (e.g., while waiting in line). 0 1 2 3

18. interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may interfere with or take over what others are doing) 0 1 2 3

Approximately when did you first notice the behaviors occurring often or very often?

Do these symptoms impair the person’s functioning in two or more settings?

Yes No

Where is the impairment? (circle all that apply)

Home School Socially

Scoring Instructions

To meet DSM-V criteria for childhood ADHD, a child must have at least 6 responses of “Often” or “Very Often” (scored 2 or 3) to the 9 inattentive items (1-9) or the 9 hyperactive-impulsive items (10-18), or both. For older adolescents and adults (age 17 and older), at least five symptoms are required. The clinician may consider ADHD as a possible diagnosis if 5 or more symptoms are scored 2 or 3 in one or both domains. In addition, the symptoms must have occurred by age 12 years, must impair the individual's functioning in two or more settings, and must not be primarily due to any other factors or conditions. Depending on the domains affected, ADHD, predominantly inattentive type; ADHD, predominantly hyperactive-impulsive type; or ADHD, combined type may be considered. Other sources of information should be considered, and an appropriate health care professional should be consulted. 

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