Institute of Living / Anxiety Disorders Center / Adult ADHD

Anxiety Disorders Center
Please complete this form and show it to your doctor or other healthcare professional.
Do you have Adult Attention-Deficit/Hyperactivity Disorder?
1. Do you have problems paying attention to details or make careless mistakes YES NO
on your work (at work, school, or home)?
2. Do you have a hard time staying focused when you are doing things (e.g. YES NO
tasks, conversations, reading)?
3. Do people often complain to you that you don’t seem to be listening when YES NO
they are talking to you?
4. Do you have a hard time following instructions and finishing tasks, chores, or YES NO
projects?
5. Do you have a hard time organizing things (e.g. your possessions, when YES NO
making plans)?
6. Do you have a hard time doing things that you don’t like to do or that require YES NO
a lot of effort, more than the average person? (e.g. unpleasant tasks)
7. Do you have a habit of losing things frequently (e.g. keys, paperwork)? YES NO
8. Do you get distracted easily by sounds or things going on around you? YES NO
9. Do you often forget to do things? YES NO
10. Are you often fidgety or have a hard time sitting still? YES NO
11. Do you often get out of your seat even when you should stay seated (e.g. YES NO
during lectures, meetings)?
12. Do you often feel restless? YES NO
13. Are people often complaining that you are loud or make a lot of noise? Is it YES NO
hard for you to do things quietly?
14. Are you often “on the go” or feel like you’re “driven by a motor”? YES NO
15. Do people often tell you that you talk too much? YES NO
16. Do you often interrupt other people? YES NO
17. Do you often blurt out answers before someone finishes asking the question? YES NO
18. Do you have a hard time waiting your turn? YES NO
19. Did you have at least some of these problems since you were a young child? YES NO
20. Have these kinds of problems been causing you a lot of problems in your life
(e.g. school, work, getting along with others)?
YES NO
200 Retreat Avenue, Hartford, CT 06106
Phone (860) 545-7685 Fax (860) 545-7156
Copyright 2012 David F. Tolin, Ph.D., Anxiety Disorders Center, The Institute of Living, Hartford, CT

You might have Attention-Deficit/Hyperactivity Disorder if all of the following are true:
You answered YES to at least 6 of questions 1, 2, 3, 4, 5, 6, 7, 8, and 9
AND/OR you answered YES to at least 6 of questions 10, 11, 12, 13, 14, 15, 16, 17, and 18
You answered YES to questions 19 and 20.
Note: This questionnaire is for informational purposes only and is not intended to function as a
psychological or psychiatric assessment. Diagnosis of psychiatric disorders requires a careful
evaluation by a trained professional.
To get help for this condition or to receive a comprehensive assessment, please call The
Institute of Living's Anxiety Disorders Center at (860) 545-7685.
200 Retreat Avenue, Hartford, CT 06106
Phone (860) 545-7685 Fax (860) 545-7156
Copyright 2012 David F. Tolin, Ph.D., Anxiety Disorders Center, The Institute of Living, Hartford, CT