*This is questionnaire used to determine the likelihood that an individual has Adult Attention Deficit Disorder (Adult ADD). It can be printed and completed on paper. For those patients coming to see Dr. Nicholas Schwartz about Adult ADD, please complete this self assessment and bring it to our first meeting.
Please answer the following questions using the scoring key below. Use the scoring key to rate the degree to which you experience these Adult Attention Deficit Disorder symptoms.
Scoring key
Doesn't describe
me at all, happens very rarely, no problem - 0
Describes me somewhat, happens sometimes, mild problem - 1
Describes me pretty well, happens often, moderate problem - 2
Describes me very well, happens very often, severe problem - 3
Instructions: Score each item from 0 to 3 using the key above.
For a quick test, score only the first item in each category except the last. In the last category (Symptoms’ Effects), complete all the questions.
MENTAL STATE
CHANGE / INITIATION
I have trouble getting started doing things __
I wait until the last moment before starting tasks __
Average for MENTAL SET CHANGE / INITIATION __
HYPER-FOCUS
I keep doing things long after I could have stopped __
I sometimes find it hard to stop doing something __
Average for HYPER-FOCUS __
EXECUTION
I often don't follow through or finish my work __
Sometimes I have time to do something important,
but just don't do it __
Average for EXECUTION __
MOTIVATION AND
ENERGY
I have trouble keeping up my motivation __
I feel like I don't have enough mental energy __
Average for MOTIVATION/ENERGY __
DISTRACTIBILITY
I am easily distracted by own thoughts __
I am easily distracted by noises, sights, etc. __
Average for DISTRACTIBILITY __
FOCUS AND
DETAILS
I don't pay attention when I should __
I fail to give close attention to details
or make careless mistakes __
Average for DETAILS __
PERSEVERANCE
I dislike tasks that involve a long series of steps __
It is hard for me to do two or three tasks in a row __
Average for PERSEVERANCE
__
MEMORY
I often forget to do things I have in mind (to do, buy) __
I am often forgetful in daily activities __
Average for BACKGROUND REMINDER PROCESSES __
TIME AND
PREPARATION
I am often late to arrive at social gatherings __
I am often late for appointments __
Average for TIME AND PREPARATION __
PERSPECTIVE/BIG
PICTURE
I waste a lot of time doing nothing __
I often lose the big picture and get lost in details __
Average for PERSPECTIVE/BIG PICTURE __
THOUGHT
ORGANIZATION
I have difficulty organizing tasks/activities __
I tend to make things more complicated
than they need to be __
Average for THOUGHT ORGANIZATION __
PHYSICAL
ORGANIZATION
I often can't find things I have filed or stored __
My personal work area is messy __
Average for PHYSICAL ORGANIZATION __
PHYSICAL
ACTIVITY
I feel
restless __
I often fidget with my hands or feet, squirm in my seat __
Average for PHYSICAL ACTIVITY __
EMOTIONAL
DYSCONTROL
I am easily frustrated __
I do things without thinking that often
don't work out well __
Average for EMOTIONAL DYSCONTROL __
MISCELLANEOUS
I don't have a
good sense of how much time has passed
when I'm doing
something
__
My skin is very sensitive to touch,
for example by clothing labels or certain kinds of cloth
__
ADD SYMPTOMS'
EFFECTS
My symptoms interfere with my work __
My symptoms interfere with my social relationships __
My symptoms interfere with my family relationships __
My symptoms lower my self-esteem __
My symptoms depress me or make me anxious __
Average for ADD SYMPTOMS EFFECTS __
If you believe you have Adult Attention Deficit Disorder and would like a consultation with Dr. Schwartz, he can be reached at his office in New York City. The phone number is 212-465-2562. The office is located at 156 Fifth Avenue, suite 414, in the Flatiron District of New York.
[About Nicholas Schwartz, M.D.]