Admin: ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Please complete this screening form if you have been requested to by a member of our team. This checklist does not confirm if you have ADHD or not but instead is there to stimulate dialogue during an assessment.

We will contact you once it has been reviewed by a member of our clinical team and explain what the next steps will be.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Full name:

Date of Birth:

Contact number:

Part A

Please 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, select the option that best describes how you have felt and conducted yourself over the past 6 months.

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

How often do you have difficulty getting things in order when you have to do a task that requires organization?

How often do you have problems remembering appointments or obligations?

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B

How often do you make careless mistakes when you have to work on a boring or difficult project?

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

How often do you misplace or have difficulty finding things at home or at work?

How often are you distracted by activity or noise around you?

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

.How often do you feel restless or fidgety?

How often do you have difficulty unwinding and relaxing when you have time to yourself?

How often do you find yourself talking too much when you are in social situations?

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?

How often do you have difficulty waiting your turn in situations when turn taking is required?

How often do you interrupt others when they are busy?

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Admin: ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

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