Which office are you being treated in?* Toms River Freehold Patient Name* First Last Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* DIRECTIONSPlease 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, place an X in the box 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. 0 = Never 1 = Rarely 2 = Sometimes 3 = Often 4 = Very OftenPART A1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?* 0 1 2 3 4 2. How often do you have difficulty getting things in order when you have to do a task that requires organization?* 0 1 2 3 4 3. How often do you have problems remembering appointments or obligations?* 0 1 2 3 4 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?* 0 1 2 3 4 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?* 0 1 2 3 4 6. How often do you feel overly active and compelled to do things, like you were driven by a motor?* 0 1 2 3 4 PART B7. How often do you make careless mistakes when you have to work on a boring or difficult project?* 0 1 2 3 4 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?* 0 1 2 3 4 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?* 0 1 2 3 4 10. How often do you misplace or have difficulty finding things at home or at work?* 0 1 2 3 4 11. How often are you distracted by activity or noise around you?* 0 1 2 3 4 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?* 0 1 2 3 4 13. How often do you feel restless or fidgety?* 0 1 2 3 4 14. How often do you have difficulty unwinding and relaxing when you have time to yourself?* 0 1 2 3 4 15. How often do you find yourself talking too much when you are in social situations?* 0 1 2 3 4 16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?* 0 1 2 3 4 17. How often do you have difficulty waiting your turn in situations when turn taking is required?* 0 1 2 3 4 18. How often do you interrupt others when they are busy?* 0 1 2 3 4 Δ
