Name
*
First Name
Last Name
Date of Birth:
*
MM
DD
YYYY
Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities).
*
Yes
No
Has difficulty sustaining attention in tasks.
*
Yes
No
Does not seem to listen when spoken to directly.
*
Yes
No
Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (eg, starts tasks but quickly loses focus and is easily sidetracked).
*
Yes
No
Has difficulty organizing tasks and activities (messy, disorganized work; has poor time management; fails to meet deadlines).
*
Yes
No
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg, schoolwork or homework; for older adolescents and adults, preparing reports, completing forms).
*
Yes
No
Loses things necessary for tasks or activities (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
*
Yes
No
Is easily distracted by extraneous stimuli (may include unrelated thoughts).
*
Yes
No
Is forgetful in daily activities (eg, doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
*
Yes
No
Often fidgets with or taps hands or feet or squirms in seat.
*
Yes
No
Often leaves seat in situations when remaining seated is expected (eg, leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
*
Yes
No
Often feels restless.
*
Yes
No
Often unable to engage in leisure activities quietly.
*
Yes
No
Is often "on the go," acting as if "driven by a motor."
*
Yes
No
Often talks excessively.
*
Yes
No
Often blurts out an answer before a question has been completed or interrupts others.
*
Yes
No
Often has difficulty waiting his or her turn (eg, while waiting in line).
*
Yes
No
Often interrupts or intrudes on others, such as taking over what others are doing.
*
Yes
No
Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
*
Yes
No
Are at least several symptoms present in two or more settings?
*
Yes
No
There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
*
Yes
No
The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder.
*
True
False
Do you have a history of heart disease or other heart problems?
*
Yes
No
Does anyone in your immediate family (mother, father, children, siblings) have a history of sudden death or ventricular arrhythmia?
*
Yes
No
Personal or family history of bipolar disorder, mania, or hypomania?
*
Yes
No
Do you have a history of drug or alcohol abuse?
*
Yes
No
Have you tried counseling with cognitive-behavioral therapy?
*
Yes
No
If you have a known anxiety disorder, have you had a prior trial of Wellbutrin or other antidepressants?
*
Yes
No
Do you have any current issues with insomnia, GI issues, or cardiac symptoms?
*
Yes
No
