ADHD Evaluation and Assessment

ADHD Diagnosis Test

Name: LifeTent Behavioral Health, LLC
Price range: $

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

What state do you live in?

How did you come across our company?

First Name

Last Name

Date of Birth

Telephone / Mobile

Email Address

Employment Status

What Pharmacy do you use? Type Name

What is the address of the pharmacy? (Street, City/Town, Massachusetts)

Do you have any of these conditions? Select all that apply.

High blood pressure with medication Extreme anxiety or agitation Motor tics or Tourette's Heart condition or heart disease Glaucoma Hyperthyroidism History of seizures Current or prior diagnosis of bulimia or anorexia nervosa None

A1a.) Do you often fails 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 has 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 does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). Has symptom persisted for a least 6 months.

Yes Not sure No

A1d.) Do you often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). Has symptom persisted for a least 6 months.

Yes Not sure No

A1e.) Do you often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). Has symptom persisted for a least 6 months.

Yes Not sure No

A1f.) Do you often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). Has symptom persisted for a least 6 months.

Yes Not sure No

A1g.) Do you often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, papenwork, eyeglasses, mobile telephones). Has symptom persisted for a least 6 months.

Yes Not sure No

A1h.) Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). Has symptom persisted for a 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, keeping appointments). Has symptom persisted for a least 6 months.

Yes Not sure No

A2a.) Do you often fidgets with or taps hands or feet or squirms in seat. Has symptom persisted for a least 6 months.

Yes Not sure No

A2b.) Do you often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). Has symptom persisted for a least 6 months.

Yes Not sure No

A2c.) Do you often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.). Has symptom persisted for a least 6 months.

Yes Not sure No

A2d.) Do you often unable to play or engage in leisure activities quietly. Has symptom persisted for a least 6 months.

Yes Not sure No

A2e.) Are you often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or un comfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). Has symptom persisted for a least 6 months.

Yes Not sure No

A2f.) Do you often talks excessively. Has symptom persisted for a least 6 months.

Yes Not sure No

A2g.) Do you often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). Has symptom persisted for a least 6 months?

Yes Not sure No

A2h.) Do you often has difficulty waiting his or her turn (e.g., while waiting in line). Has symptom persisted for a least 6 months?

Yes Not sure No

A2i.) Do you often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving per mission; for adolescents and adults, may intrude into or take over what others are doing). Has symptom persisted for a least 6 months?

Yes Not sure No

B) Were several inattentive or hyperactive-impulsive symptoms present prior to age 12 years.

Yes Not sure No

C) Were several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

Yes Not sure No

D) Is there a clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

Yes Not sure No

E) Have you been diagnosed with schizophrenia or another psychotic disorder or mental disorder such as mood disorder, anxiety disorder, dissociative disorder, or personality disorder or are you experiencing substance intoxication or withdrawal?

Yes Not sure No

Any other information you need to share?

What state do you live in?

How did you come across our company?

First Name

Last Name

Date of Birth

Telephone / Mobile

Email Address

Employment Status

What Pharmacy do you use? Type Name

What is the address of the pharmacy? (Street, City/Town, Massachusetts)

Do you have any of these conditions? Select all that apply.

Yes Not sure No

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

Yes Not sure No

A1h.) Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). Has symptom persisted for a least 6 months.

Yes Not sure No

A2a.) Do you often fidgets with or taps hands or feet or squirms in seat. Has symptom persisted for a least 6 months.

Yes Not sure No

A2c.) Do you often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.). Has symptom persisted for a least 6 months.

Yes Not sure No

A2d.) Do you often unable to play or engage in leisure activities quietly. Has symptom persisted for a least 6 months.

Yes Not sure No

A2f.) Do you often talks excessively. Has symptom persisted for a least 6 months.

Yes Not sure No

A2g.) Do you often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). Has symptom persisted for a least 6 months?

Yes Not sure No

A2h.) Do you often has difficulty waiting his or her turn (e.g., while waiting in line). Has symptom persisted for a least 6 months?

Yes Not sure No

B) Were several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

Yes Not sure No

C) Were several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

Yes Not sure No

D) Is there a clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

Yes Not sure No

Any other information you need to share?

ADHD Diagnostic Criteria Questions

ADHD Diagnosis Test

TeleHealth Visit

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