Womens Adhd Self Assessment Form – Fill Out and Use This PDF

_____

1.

I daydreamed a lot in school.

_____

2.

My mind wandered, even when I TRIED to listen to the teacher.

_____

3.

In class, I didn’t hear the teacher's instructions.

_____

4.

I made careless mistakes on tests.

_____

5.

I often lost or misplaced things.

_____

6.

I got teased for being “spacey.”

_____

1.

I got in trouble for talking in class.

_____

2.

I was a tomboy.

_____

3.

It was hard for me to sit still in class.

_____

4.

I felt best when I was moving around – playing sports or dancing.

_____

5.

It was hard to fall asleep at bedtime because thoughts were bouncing around in my brain.

_____

6.

I often doodled or fidgeted when I had to sit still.

_____

7.

My friends called me “hyper.”

_____

8.

When sitting, I tended to "tip" my chair or jiggle my legs.

_____

1.

I interrupted others, even though I tried not to.

_____

2.

Sometimes, when I was upset, I’d blurt out things that I didn’t mean.

_____

3.

I acted silly or “crazy” with my friends.

_____

4.

I acted on the spur of the moment, never thinking of the trouble I’d get into.

_____

5.

As a teenager, I sometimes drove too fast, or took other risks while driving.

Productivity

_____

1.

In school, I didn't finish seatwork quickly as the rest of the class.

_____

2.

The demands of high school felt overwhelming sometimes.

_____

3.

I had to work much harder and stay up later than others to do well in school.

_____

4.

I studied or did homework late into the night.

Problems with initiation

_____

1.

I had trouble getting started on my homework.

______

2.

It was hard for me to begin working on a project unless someone was there to keep me on track.

_____

3.

I worked better with others than when I worked alone.

Problems with follow-through/perseverance

_____

1.

It was hard for me to complete long-term school projects.

_____

2.

I dabbled in many hobbies or activities, but never really persevered in my efforts.

_____

3.

Although I took different types of lessons as a child, I rarely or never practiced.

Problems with underarousal

_____

1.

I felt sleepy when sitting in class, but felt energetic as soon as I stood up and moved.

_____

2.

It was difficult to get up in the morning.

_____

3.

I wasn't alert until late in the morning.

_____

4.

I didn't seem to have as much energy as most of my friends.

Procrastination problems

_____

1.

I was smart, but got by doing everything at the last minute.

_____

2.

I handed in my homework late, if I did it at all.

_____

3.

The only way I could really study for a test was to stay up very late the night before.

_____

1.

I didn't do as well in school as I felt I should have.

_____

2.

I got by on my intelligence, and didn't really try hard in school.

_____

3.

My parents and teachers told me I could do much better if I tried.

_____

4.

I started each grading period with good intentions, but could never sustain them.

_____

1.

My room looked like a "disaster" area.

_____

2.

My backpack/book bag/desk was messy.

_____

3.

I had trouble being organized.

_____

4.

I had trouble keeping track of assignments, long-term projects, and due dates.

_____

1.

I arrived late for scheduled activities.

_____

2.

I often lost track of time.

_____

3.

I stayed up late, then had trouble getting up in the morning.

Problems with fine/gross motor control

_____

1.

My handwriting was messy.

_____

2.

I was physically awkward and did poorly in sports.

_____

3.

I tended to bump into things – corners of tables, door frames, etc.

_____

1.

I was a slow reader.

______

2.

When reading, my mind wandered.

_____

3.

Typically, after reading a textbook, I could not answer the questions at the end

of the chapter.

_____

4.

I needed to reread information to be sure that I understand it.

_____

5.

I didn't read for pleasure.

Writing problems

_____

1.

Writing assignments were difficult for me.

_____

2.

I had lots of ideas, but couldn’t organize them well when writing.

_____

3.

I could explain what I knew verbally, but just couldn’t get it down on paper.

Memory problems

_____

1.

I had trouble remembering the directions for assignments.

_____

2.

Even when I studied, I couldn’t recall the information on a test.

_____

3.

I was forgetful and absentminded.

_____

1.

I felt shy and self-conscious around my classmates.

_____

2.

Even when I had something to say, I rarely raised my hand to volunteer in class.

_____

3.

I had only a few friends during school years.

_____

4.

I didn’t date or rarely dated in high school.

_____

1.

Other girls called me “mean” or “bossy.”

_____

2.

I felt different from other girls.

_____

3.

Other girls didn’t like me, but I didn’t understand why.

_____

4.

It was hard for me to keep up with the conversation of a group of girls.

_____

5.

I fought and argued with my friends.

_____

6.

In conversation, I’d say something dumb or couldn’t think of anything to say.

_____

7.

I was very sensitive to teasing.

_____

1.

I felt worried and anxious.

_____

2.

I felt moody and depressed for no reason.

_____

3.

I dreaded being called on by the teacher.

_____

4.

I didn't like going to school.

_____

5.

I became very anxious before tests.

_____

6.

I was irritable as a teenager.

_____

7.

I cried easily.

_____

1.

I wish my parents had understood how hard high school was for me.

_____

2.

It felt as if my parents criticized me a lot.

_____

3.

My mother and I were in conflict during my high school years.

_____

4.

I was repeatedly humiliated or criticized by teachers in the school setting.

_____

1.

I feel a sense of shame or regret, as I look back on things I did in high school.

_____

2.

I wasn’t really good at anything.

_____

3.

I didn't feel good about myself during my school years.

____

1.

I was impatient and easily frustrated.

_____

2.

Although I controlled myself at school, I had screaming arguments at home with my family.

_____

3.

I quit a task if I encountered difficulty.

_____

4.

I lost my temper when frustrated.

Risk-taking behavior

_____

1.

I took risks when driving an automobile.

_____

2.

I started smoking at a younger age than many of my friends.

_____

3.

I was sexually active earlier than other girls.

_____

4.

I drank and experimented with drugs in high school or earlier.

_____

5.

I abused alcohol or other substances in high school or earlier.

Oppositional/defiant behavior

_____

1.

I got into trouble as a teenager.

_____

2.

I rebelled against my parents.

_____

3.

My parents didn't like the kids that I hung out with in high school.

_____

4.

I skipped classes in high school.

_____

5.

I fought with my parents over rules and curfew.

_____

6.

My parents didn’t approve of my boyfriend in high school.

_____

7.

I was very argumentative.

_____

8.

I couldn’t take “no” for an answer.

Problems with disordered eating

_____

1.

I ate compulsively as a child or teen.

_____

2.

I developed a pattern of bulimia.

_____

3.

I became overweight after puberty.

_____

4.

I repeatedly dieted without success.

_____

5.

I binged on certain foods until I felt stuffed, even sick.

_____

1.

I tend to overlook details.

_____

2.

Forms are difficult for me to complete correctly without overlooking something.

_____

3.

It is hard for me to listen for long periods of time – in a lecture, seminar, or training class.

_____

4.

My mind tends to wander when I’m reading or when listening to something that is not interesting.

_____

1.

I am easily sidetracked, and wander from one task to the next as something catches my attention.

_____

2.

I jump from topic to topic in conversation, forgetting what I started to say.

_____

3.

I have difficulty concentrating when there is noise or conversation near me.

_____

4.

It is very difficult for me to get back on track after an interruption.

_____

1.

I tend to "hyperfocus" for long periods of time on certain activities.

_____

2.

When engaging in certain activities, I completely lose track of time.

_____

3.

When I'm really concentrating, I don’t hear what people say to me.

_____

1.

It is difficult for me to stop an activity when it is time to do something else.

_____

2.

I can’t tear myself away from an activity when I’m really engrossed.

_____

1.

I tend to fidget or doodle.

_____

2.

I talk so fast that others "can't get a word in."

_____

3.

I hate to sit for long periods, and find an excuse to move around.

_____

4.

I seem to need less sleep than other women.

_____

5.

I have a high energy level compared to many women.

_____

6.

My activity level makes the people around me uncomfortable.

_____

1.

I buy on impulse.

_____

2.

I interrupt others in conversation, even when I try not to.

_____

3.

I have impulsively jumped from one job to another.

_____

4.

I have impulsively quit a job without considering the consequences.

_____

5.

I tend to "blurt out" whatever I'm thinking; though I may later regret it.

_____

6.

I have made major life decisions with little planning or forethought.

_____

1.

I just can’t seem to juggle the number of activities and commitments that my friends

seem to manage.

_____

2.

I have felt overwhelmed by responsibilities at certain times in my life.

_____

3.

It seems much harder for me than for others to take care of the tasks of everyday tasks.

_____

4.

Keeping up with job demands has been difficult for me.

_____

1.

Despite my best intentions, it is often hard for me to get started on a project.

_____

2.

Getting started is much easier when I work with someone else.

_____

1.

I tend not to finish doing laundry - it's always "in progress."

_____

2.

I have many unfinished projects that I intend to "get around to."

_____

3.

I pick up and drop hobbies or interests.

_____

4.

I don't meet the long-term goals I set for myself.

_____yes _____no

I was diagnosed with learning disabilities in school.

Reading difficulties

_____

1.

I rarely read for pleasure.

_____

2.

While reading, I can concentrate only if the material is very interesting to me.

_____

3.

I have difficulty recalling information that I have read.

_____

4.

I read slowly.

_____

5.

I must reread text in order to fully comprehend it.

Writing difficulties

_____

1.

Writing papers is difficult for me.

_____

2.

I have difficulty organizing my thoughts in writing, even when I am very familiar with the subject.

_____

3.

I am much more comfortable explaining something verbally than in writing.

_____

4.

Difficulty with writing has caused problems for me at work.

_____

5.

Spelling is difficult for me.

_____

6.

Punctuation and grammar are difficult for me.

Memory problems

_____

1.

I need to speak the moment I think of something in order not to forget my thought.

_____

2.

I misplace personal belongings.

_____

3.

I have difficulty recalling the names of common objects or others.

_____

4.

I am absentminded.

_____

5.

I have to write things down to remember them.

_____

6.

I forget to do thing that I intend to do.

_____

7.

I have difficulty remembering multi-step directions or multi-item lists.

_____

8.

My recall is variable and unpredictable.

Problems with motor control

_____

1.

I have poor handwriting.

_____

2.

The legibility of my handwriting is variable.

_____

3.

I tend to bump into or trip over things.

_____

4.

I have poor motor coordination.

_____

1.

My parenting is inconsistent.

_____

2.

I can’t develop routines for myself, much less establish them for my child(ren).

_____

3.

I have difficulty not losing my temper with my child(ren).

_____

1.

I have received unsatisfactory performance ratings at work.

_____

2.

I have quit a job in order to avoid being fired.

_____

3.

I have changed jobs many times, never finding the “right” job.

____ 1.

I don't keep up with housekeeping tasks in a regular, consistent manner.

_____

2.

My home/office are filled with disorganized piles of papers.

_____

3.

My wardrobe is disorganized and in disarray.

_____

4.

I typically neglect making routine medical/dental appointments.

_____

5.

I neglect to take care of routine automobile maintenance.

_____

6.

Laundry is done at the last possible moment.

_____

7.

I wait until my car is nearly out of gas before filling the tank.

_____

8.

My life is filled with numerous, avoidable crises.

_____

1.

I have difficulty managing my money.

_____

2.

I have large credit card debt.

_____

3.

I have difficulty balancing my checkbook.

_____

4.

I tend to file my tax forms late.

_____

5.

My financial record-keeping is chaotic.

_____

6.

Some years, I have not filed my income tax return.

_____

7.

I have a poor credit rating.

_____

Depression

_____

Anxiety/panic disorder

_____

Bipolar disorder

_____

Post-traumatic stress disorder

_____

Obsessive-compulsive disorder

_____

1.

I tend to hide many aspects of my life, fearing that I’ll be judged negatively.

_____

2.

People think too highly of me, and I fear that I’ll be “found out.”

_____

3.

I have often felt “stupid” because I couldn’t seem to accomplish things that others could.

_____

1.

I have felt demoralized by my failures.

_____

2.

I have felt depressed for "no reason."

_____

3.

I am anxious and worry a lot.

_____

4.

I have fears and phobias.

_____

5.

I suffer from panic attacks.

_____

6.

I tend to be irritable and overreact to frustration.

_____

7.

My moods vary from day to day.

_____

1.

I have strong perfectionist tendencies.

_____

2.

Even in unimportant tasks, I feel compelled to do a perfect, micro-detailed job.

_____

3.

My perfectionism keeps me from completing tasks in a timely manner.

_____

4.

In my efforts to do a good job, I seem to make things more complicated than they need to be.

_____

5.

There are periods when I've become obsessed by a particular thought or concern.

_____

1.

I hate to wait.

_____

2.

I become very frustrated and angry in traffic.

_____

3.

I lose my temper if my children are noisy or argumentative.

_____

4.

I quit tasks out of frustration.