Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during an appointment.
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Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.
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