Your name:

Please indicate for each item what best describes your behavior during the past 6 months.

Items:Never or rarelySometimesOftenVery often
1. Fail to give close attention to details or make careless mistakes in my work
2. Fidget with hands or feet or squirm in seat
3. Have difficulty sustaining my attention in tasks or fun activities
4. Leave my seat in situations in which seating is expected
5. Don't listen when spoken to directly
6. Feel restless
7. Don't follow through on instructions and fail to finish work
8. Have difficulty engaging in leisure activities or doing fun things quietly
9. Have difficulty organizing tasks and activities
10. Feel "on the go" or "driven by a motor"
11. Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort
12. Talk excessively
13. Lose things necessary for tasks or activities
14. Blurt out answers before questions have been completed
15. Am easily distracted
16. Have difficulty awaiting turn
17. Am forgetful in daily activities
18. Interrupt or intrude on others

How old were you when these problems with attention, impulsiveness, or hyperactivity first began to occur? years old

To what extent do the problems you may have indicated above interfere with your ability to function in each of these areas of life activities?

Areas:Never or rarelySometimesOftenVery often
In my home life with my immediate family
In my work or occupation
In my social interactions with others
In my activities or dealing in the community
In any educational activities
In my dating or marital relationship
In my management of my money
In my driving of a motor vehicle
In my leisure or recreational activities
In my management of my daily responsibilities

Instructions: Again, please indicate what best describes your behavior during the past six months.

Items:Never or rarelySometimesOftenVery often
1. Lose temper
2. Argue
3. Actively defy or refuse to comply with requests or rules
4. Deliberately annoy people
5. Blame others for my mistakes or misbehavior
6. Am touchy or easily annoyed by others
7. Am angry or resentful
8. Am spiteful or vindictive