ADHD Evaluation and Assessment

ADHD DSM-5 Diagnostic Criteria Questionnaire

Name: LifeTent Behavioral Health, LLC
Price range: $

Attention-Deficit / Hyperactivity Disorder (ADHD) assessment questions. Complete and submit this form.

Attention-Deficit / Hyperactivity Disorder (ADHD) assessment questions. Fill out this form and submit it. We will get back to you to review your answers.

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First Name

Last Name

Date of Birth

Telephone / Mobile

Email Address (you will receive your responses via this email.)

Employment Status

Inattention Symptoms

A1a.) Do you often fail to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). Has symptom persisted for a least 6 months.

Yes Not sure No

A1b.) Do you often have difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). Has symptom persisted for a least 6 months.

Yes Not sure No

A1c.) Do you often not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1d.) Do you often not follow through on instructions and fail to finish schoolwork, chores, or workplace duties (e.g., start tasks but quickly lose focus and become easily sidetracked)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1e.) Do you often have difficulty organizing tasks and activities (e.g., trouble managing sequential tasks, keeping materials and belongings in order, or maintaining organized work; poor time management; failure to meet deadlines)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1f.) Do you often avoid, dislike, or feel reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork, homework, preparing reports, completing forms, or reviewing lengthy papers for older adolescents and adults)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1g.) Do you often lose things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile phones)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1h.) Are you often easily distracted by extraneous stimuli (for older adolescents and adults, this may include unrelated thoughts)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A1i.) Are you often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, or keeping appointments)? Has this symptom persisted for at least 6 months?

Yes Not sure No

Hyperactivity and Impulsivity Symptoms

A2a.) Do you often fidget with or tap your hands or feet, or squirm in your seat? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2b.) Do you often leave your seat in situations where remaining seated is expected (e.g., leaving your place in the classroom, office, or other settings that require staying in place)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2c.) Do you often run about or climb in situations where it is inappropriate? (Note: In adolescents and adults, this may manifest as feelings of restlessness.) Has this symptom persisted for at least 6 months?

Yes Not sure No

A2d.) Are you often unable to play or engage in leisure activities quietly? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2e.) Are you often “on the go,” acting as if “driven by a motor” (e.g., unable or uncomfortable being still for extended periods, such as in restaurants or meetings; may be perceived by others as restless or difficult to keep up with)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2f.) Do you often talk excessively? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2g.) Do you often blurt out answers before a question is completed (e.g., finish people’s sentences or struggle to wait your turn in conversation)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2h.) Do you often have difficulty waiting your turn (e.g., while waiting in line)? Has this symptom persisted for at least 6 months?

Yes Not sure No

A2i.) Do you often interrupt or intrude on others (e.g., butt into conversations, games, or activities; use others' belongings without permission; for adolescents and adults, take over what others are doing)? Has this symptom persisted for at least 6 months?

Yes Not sure No

ADHD Diagnostic Criteria Questions

ADHD DSM-5 Diagnostic Criteria Questionnaire

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ADHD Diagnostic Criteria Questions

ADHD DSM-5 Diagnostic Criteria Questionnaire

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