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Grassroot Psychiatry Mental Health Clinic
Take care of your health and happiness with us
Primary Menu
Home
About
Team
Services
Anxieties
Depression
Panic Attacks
ADHD
Psychosis
PTSD
Addictions
Substance Abuse
Bipolar Disorders
Mood Disorders
Schizophrenia
ODD & DSDM
Policies
Forms
Contact
Questionnaire Assessment Form
Patient Name
*
Phone Number
*
Email Address
*
How often the do you makes careless mistakes/lacks attention to detail?
Often
Not often
How often do you lack sustained attention in tasks or play activities?
Often
Not often
How often are you a poor listener, even in the absence of obvious distraction?
Often
Not often
How often do you fail to follow through on tasks and instructions?
Often
Not often
How often do you have difficulty with organization, time management, and deadlines?
Often
Not often
How often do you avoid tasks requiring sustained mental effort?
Often
Not often
How often do you lose things necessary for tasks or activities?
Often
Not often
How often are you easily distracted (including unrelated thoughts)?
Often
Not often
How often do are you forgetful in daily activities?
Often
Not often
How often do you fidget, tap hands, or squirms in seat?
Often
Not often
How often do you leave your seat in situations when remaining seated is expected?
Often
Not often
How often do you engage in excessive running/climbing or feelings of restlessness?
Often
Not often
How often do you have difficulty with quiet, leisure activities?
Often
Not often
How often are you on the go “on the go” acting as if “driven by a motor”?
Often
Not often
How often do you unconsciously engage in excessive talking?
Often
Not often
How often do you blurt out answers before questions are even completed?
Often
Not often
How often do you have difficulty waiting turn?
Often
Not often
How often do you interrupt or intrudes on others?
Often
Not often
How often do jump from task to task and projects to project without completing the first?
Often
Not often
How often do you have difficulty keeping your immediate surrounding clean and tidy?
Often
Not often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Often
Not often
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
Often
Not often
How often do you have difficulty unwinding and relaxing when you have time to yourself?
Often
Not often
When you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?
Often
Not often
How often do you find yourself talking too much when you are in social situations?
Often
Not often
How often do you interrupt others when they are busy?
Often
Not often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Often
Not often
How often do you procrastinate or postpone completing a required task to the last meeting?
Often
Not often
When did you have a Psychological Evaluation to confirm/rule out ADHD?
What medication have you taken for ADHD in the past?
Who prescribed this medication for you?
What state did you live when the medication was prescribed for you?
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Email
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Patient
Appointment
