Amen Adult Attention Deficit Disorder Checklist Name First Last Name of person you are rating First Last Date MM slash DD slash YYYY Read this list of behaviors and rate yourself (or the person who has asked you to rate them) on each behavior listed. Past HistoryHistory of ADHD symptoms in childhood, such as distractibility, short attention span, impulsivity or restlessness. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently History of not living up to potential in school or work (report cards with comments such as "not living up to potential." 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently History of frequent behavioral problems in school. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently History of bed wetting past age 5. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Family history of ADHD, learning problems, mood disorders, or substance abuse problems. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Short attention span, unless very interested in something. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Easily distracted tendency to drift away (although at times can be hyperfocused) 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Lacks attention to detail, due to distractibility. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble listening carefully to directions. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Frequently misplaces things. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Skips around while reading, or goes to the end first, trouble staying on task. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Difficulty learning new games, because it is hard to stay on track during directions. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Easily distracted during sex, causing frequent breaks or turn-offs during lovemaking. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Poor listening skills 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency to be easily bored (tunes out) 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Restlessness, constant motion, legs moving, fidgeting 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Has to be moving in order to think. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble sitting still, such as trouble sitting in one place for too long, sitting at a desk job for long periods, sitting through a movie. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently An internal sense of anxiety or nervousness. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Impulsive, in words and/or actions (such as spending). 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Say just what comes to mind without considering its impact (tactless). 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble going through established channels, trouble following proper procedure, an attitude of "read the directions when all else fails." 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Impatient, low frustration tolerance. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently A prisoner of the moment. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Frequent traffic violations. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency to embarrass others. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Lying or stealing on impulse. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Poor organization and planning, trouble maintaining an organized work/living area. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Chronically late or chronically in a hurry. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Often have piles of stuff. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Easily overwhelmed by tasks of daily living. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Poor financial management (late bills, check book a mess, spending unnecessary money on late fees. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Chronic procrastination or trouble getting started. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Starting projects but not finishing them, poor follow through. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Enthusiastic beginnings but poor endings. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Spends excessive time at work because of inefficiencies. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Inconsistent work performance. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Chronic sense of under achievement, feeling you should be much further along in your life than you are. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Chronic problems with self-esteem. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Sense of impending doom. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Mood swings. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Negativity 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Frequent feeling of demoralization or that things won't work out for you. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble sustaining friendships or intimate relationships, promiscuity. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble with intimacy. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency to be immature. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Self-centered; immature interests. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Failure to see others' needs or activities as important. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Lack of talking in a relationship. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Verbally abusive to others. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Prone to hysterical outbursts. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Avoids group activities. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Trouble with authority. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Quick responses to slights that are real or imagined. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Rage outbursts, short fuse. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Rage outbursts, short fuse. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Frequent search for high stimulation (bungee jumping, gambling, high stress jobs, doing many things at once) 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency toward additions (food, alcohol, drugs, work) 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency to worry needlessly and endlessly. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Switches around numbers, letters or words. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Turn words around in conversation. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Poor writing skills (hard to get information from brain to pen). 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Poor handwriting, often prints. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Coordination difficulties. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Performance becomes worse under pressure. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Test anxiety, or during tests your mind tends to go blank. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently The harder you try, the worse it gets. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Work or school work deteriorates under pressure. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Tendency to turn off or become stuck when asked questions in social situations. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Falls asleep or becomes tired while reading. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Difficulty falling asleep, may be due to too many thoughts at night. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Difficulty coming awake (may need coffee or other stimulant or activity before feeling fully awake). 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Periods of low energy, especially early in the morning and in the afternoon. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Frequently feeling tired. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Startles easily. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently Sensitive to touch, clothes, noise, and light. 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Very Frequently CAPTCHA
