Amen ADD Subtype Checklist Date MM slash DD slash YYYY Name First Last Name of rater if other than self First Last Please rate the following statements on a scale of 0-4 as they apply to you or the person you are rating. 1. Often fails to give close attention to details or makes careless mistakes in school work, work, or other activities 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 2. Often has difficulty sustaining activities in tasks or play activities 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 3. Often does not seem to listen when spoken to directly 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 5. Often has difficulty organizing tasks and activities 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as paperwork, schoolwork, or homework) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 7. Often loses things necessary for tasks or activities (e.g., school assignments, pencils, books, or tools) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 8. Is often easily distracted by extraneous stimuli 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 9. Is often forgetful in daily activities 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 10. Often fidgets with hands or feet or squirms in seat 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 11. Often leaves seat in classroom or in other situations in which remaining seated is expected 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 12. Often runs about or climbs excessively in situations in which it is inappropriate (in teens or adults, may be limited to subjective feeling of restlessness) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 13. Often has difficulty playing or engaging in leisure activities quietly 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 14. Is often "on the go" or often acts as if "driven by a motor" 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 15. Often talks excessively 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 16. Often blurts out answers before questions have been completed 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 17. Often has difficulty waiting turn 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 18. Often interrupts or intrudes on others (e.g., butts into conversations or games) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 19. Excessive daydreaming 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 20. Often complains about being bored 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 21. Often appears to be apathetic or unmotivated 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 22. Frequently tired, sluggish or slow moving 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 23. Frequently spacey or internally preoccupied 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 24. Excessive or senseless worrying 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 25. Disorganized or super organized 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 26. Oppositional, argumentative 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 27. Strong tendency to get locked into negative thoughts, having the same thought over and over 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 28. Tendency towards compulsive behavior 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 29. Intense dislike for change 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 30. Tendency to hold grudges 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 31. Trouble shifting attention from subject to subject 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 32. Difficulties seeing options in situations 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 33. Tendency to hold on to own opinions and not listen to others 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 34. Tendency to get locked into a course of actions, whether or not it is good for the person 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 35. Needing to have things done a certain way or you become upset 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 36. Others complain you worry too much 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 37. Moodiness 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 38. Negativity 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 39. Low energy 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 40. Frequent irritability 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 41. Tendency to be socially isolated 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 42. Frequent feelings of hopelessness, helplessness or excessive guilt 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 43. Lowered interest in things that are usually considered fun 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 44. Sleep changes (too much or too little) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 45. Chronic low self-esteem 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 46. Short fuse or periods of extreme irritability 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 47. Periods of rages with little provocation 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 48. Often misinterprets comments as negative when they are not 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 49. Irritability tends to build, then explodes, then recedes; often tired after a rage. 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 50. Periods of spaciness or confusion 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 51. Periods of panic and/or fear for no specific reason 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 52. Visual changes, such as seeing shadows or objects changing shape 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 53. Frequent periods of de ja vu (feeling of being somewhere before even though you never have) 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 54. Sensitivity or mild paranoia 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 55. Headaches or abdominal pain of uncertain origin. 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 56. History of a head injury or family history of violence or explosiveness 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 57. Dark thoughts, may involve suicidal or homicidal thoughts 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies 58. Periods of forgetfulness or memory problems 0 - does not apply 1 - rarely applies 2 - sometimes applies 3- often applies 4 - very often applies I. Inattention 1-9 and 19-23 >=6 II. Impulsive/Hyperactive 10-18 >= 6 III. Over-focused 24-36 >= 5 IV. Limbic/Depression 37-45 >= 5 V. Temporal Lobe 46-48 >= 6CAPTCHA
