First name of patient:
Surname of patient:
DOB of patient:
Your name:
Your surname:
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Never
Occasionally/Sometimes**
Often
Always
1. he/she is able to complete projects that he/she starts (whether for work, hobbies, or home life)
2. When assigned a task that requires organization, he/she is able to organize and order things accordingly.
3. he/she is able to keep appointments reliably.
4. he/she is able to start tasks on time, including those that require some thought.
5. he/she fidgets and squirms with his/her hands or feet.
6. he/she feels overly active and compelled to do things.
7. he/she makes careless mistakes.
8. he/she finds it difficult to keep attention on anything he/she is doing.
9. he/she finds it difficult to concentrate on what people are saying to him/her.
10. he/she misplaces things or has difficulty finding them.
11. he/she becomes easily distracted by noise or activity around him/her.
12. he/she leaves his/her seat during meetings or other situations where remaining seated is expected.
13. he/she has difficulty relaxing or unwinding when he/she has time to himself/herself.
14. he/she finds himself/herself talking too much in social occasions.
15. he/she finds himself/herself finishing the sentences of other people while talking to them.
16. he/she has difficulty waiting his/her turn in situations where taking turns is required.
17. he/she interrupts other people when they are busy.
