| RPT |
|Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.>
|
| ASRS-6 screening score = <-Total->
|
| The total score range is between 0 and 25. A score of 14 or higher is
| considered clinically significant, indicating the need for additional
| assessment. This test is intended for use as a screening tool only and
| should not be used in isolation to diagnose ADHD without additional
| supporting evidence such as collateral information, academic/occupational
|for DSM-5 (ASRS-6)
| records, and a thorough psychosocial history. For the purposes of
| diagnosing ADHD, cognitive testing has decreased reliability and
| validity and is not required for diagnosis and treatment.
|
|
|Questions and Answers:
|
| 1. How often do you have difficulty concentrating on what people say to
| you, even when they are speaking to you directly?
| <*Answer_8695*>
|
| 2. How often do you leave your seat in meetings or other situations in
| which you are expected to remain seated?
| <*Answer_8696*>
| 3. How often do you have difficulty unwinding and relaxing when you have
| time to yourself?
| <*Answer_8697*>
| 4. When you're 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?
| <*Answer_8698*>
| Date Given: <.Date_Given.>
| 5. How often do you put things off until the last minute?
| <*Answer_8699*>
| 6. How often do you depend on others to keep your life in order and
| attend to details?
| <*Answer_8700*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Clinician: <.Staff_Ordered_By.>
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
|
