ADULT ATTENTION DEFICIT QUESTIONNAIRE

 

 

 

THIS QUESTIONNAIRE IS FOR ADULTS WHO SUSPECT THEY MAY HAVE PROBLEMS WITH ATTENTION.  IT IS TO BE COMPLETED  BY A PERSON WHO IS CLOSE TO THE ADULT WITH SUSPECTED ATTENTION PROBLEMS (IE. FRIEND, FAMILY MEMBER OR CO-WORKER).  PLEASE RETURN TO:

 

DR. ROBERT C. ALLEN MD, NEIGHBORHOOD FAMILY CARE

 

516 LINN STREET

ALLEGAN MI 49010

FAX: 866.708.5055

drallen@onebox.com

 

It is preferred if you could fax or email form once it is complete

 

 

· Never = 0

· Rarely = 1

· Occasionally = 2

· Frequently = 3

· Often = 4

Disorganization

_____ Is the individual always in a hurry?

_____ Does the individual have trouble planning and being organized?

_____ Does work to pile up?

_____ Are small tasks overwhelming?

_____ Is it hard to handle things such as paying the bills, balancing the
checkbook, or running errands?

_____ Is there a noticeable problem with getting a task started and then
finishing it?

_____ Does the individual procrastinate?

_____ Does the person take too much time to complete a task?

_____ Is work performance inconsistent?

_____ Are things constantly switched up such as stories, words, numbers, or
letters?

Energy

_____ Does the person become tired often and easily?

_____ Are there times the individual experiences low energy levels primarily in
the morning or afternoon hours?

History

_____ Are there any symptoms to include attention problems, distractibility,
restlessness, or impulsiveness?

_____ Is there history of frequent behavioral problems, typically seen more in
males than in females?

_____ If for a child, has he or she received report cards with comments such as
"acting up", "not doing well", "does not pay attention", "will not sit still",
or "not living up to full potential"?

_____ For the child, has he or she had trouble with bedwetting after age five?

_____ Is there family history of ADD, ADHD, or other types of mental illness?

Impulsiveness

_____ For adults, does the person get many traffic violations?

_____ Does the individual often change jobs?

_____ Does the person like to embarrass other people?

_____ Is there a problem with lying or stealing?

_____ Does the person blurt out words without thinking of consequences?

_____ Are there the signs of impulsive action?

_____ Is it difficult to coordinate things?

_____ Does the person have trouble with writing skills, specifically cursive
handwriting?

Negativity

_____ Is there the presence of low self-esteem?

_____ Does the person undergo mood swings?

_____ Is the person always negative?

_____ Does the individual see things as "gloom and doom"?

_____ Is there a constant feeling of under achievement?

_____ Is rationalization difficult?

_____ Does the person have trouble making and keeping friendships?

_____ Is verbal abuse or a tendency to have hysterical outbursts common?

_____ Is the individual immature, self-centered, or have problems with accepting
authority?

_____ Does the person avoid group activities?

Pressure

_____ Is performance under pressure worse?

_____ During test taking, does the mind simply go blank?

_____ Does it seem that the harder the person tries doing something the worse it
becomes?

_____ When there is pressure, does homework or work deteriorate?

_____ Does the individual have trouble answering a question in a social setting?

_____ Does the person deal with fatigue while reading or does he or she fall
asleep easily?

Restlessness

_____ Does the person have to be moving to think?

_____ Is there constant fidgeting, specifically leg and/or arm movement?

_____ Is sitting still longer than 10 minutes difficult?

Sensation

_____ Does the person tend to startle easily?

_____ Is there sensitivity to light, noise, touch, and clothing?

Short Attention Span

_____ Is there a problem with lack of attention to detail?

_____ Is the person easily distracted?

_____ Is there a short attention span, unless highly interested in something?

_____ Are there issues with listening to directions?

_____ Does the person "drift off" or "daydream"?

_____ When reading, does the person jump around going to the end of the book to
the middle, back to the end, and to the beginning?

_____ Do things get misplaced often?

_____ Does the person have poor listening skills?

_____ Does the person have a hard time learning new games or have trouble
following instructions?

_____ For an adult, is there easy distraction during times of intimacy?

_____ Does the person deal with boredom?

Sleep

_____ Does the person have trouble falling and staying asleep?

_____ Does the person have trouble waking up, especially without some type of
stimulation?

Stimulation

_____ Does the person have a need for adrenaline stimulation through extreme sports such as skydiving or bungee jumping, or perhaps work in high stress jobs?

_____ Is conflict an ongoing problem?

_____ Is the person argumentative?

Stuck

_____ Does the person worry excessively?

_____ Are there signs of food, drug, alcohol, or work addiction?

Temper

_____ Does the person have frequent outbursts of rage?

_____ Is the individual quick to respond to minor or imagined situations?