| RPT |
|Adult ADHD Self-Report Scale Symptom Checklist (ASRS)
| Gender: <.Patient_Gender.>
|other diagnostic activities.
|
| ASRS Scores:
|
| Part A
| ------
| Number of Items Endorsed: <-Total Part A->
|
| <*Answer_7771*>
|
|
| Part B
| ------
| Notable Responses: <*Answer_7772*>
|
| Questions and Answers:
|
| 1. How often do you have trouble wrapping up the final details of
| a project, once the challenging parts have been done?
| <*Answer_9331*>
|
| Date Given: <.Date_Given.>
| 2. How often do you have difficulty getting things in order when
| you have to do a task that requires organization?
| <*Answer_9332*>
|
| 3. How often do you have problems remembering appointments or
| obligations?
| <*Answer_9333*>
|
| 4. When you have a task that requires a lot of thought, how
| often do you avoid or delay getting started?
| Clinician: <.Staff_Ordered_By.>
| <*Answer_9334*>
|
| 5. How often do you fidget or squirm with your hands or feet
| when you have to sit down for a long time?
| <*Answer_9335*>
|
| 6. How often do you feel overly active and compelled to do things,
| like you were driven by a motor?
| <*Answer_9336*>
|
| Location: <.Location.>
| 7. How often do you make careless mistakes when you have to work on
| a boring or difficult project?
| <*Answer_9337*>
|
| 8. How often do you have difficulty keeping your attention when you
| are doing boring or repetitive work?
| <*Answer_9338*>
|
| 9. How often do you have difficulty concentrating on what people
| say to you, even when they are speaking to you directly?
|
| <*Answer_9339*>
|
| 10. How often do you misplace or have difficulty finding things at
| home or at work?
| <*Answer_9340*>
|
| 11. How often are you distracted by activity or noise around you?
| <*Answer_9341*>
|
| 12. How often do you leave your seat in meetings or other situations
| Veteran: <.Patient_Name_Last_First.>
| in which you are expected to remain seated?
| <*Answer_9342*>
|
| 13. How often do you feel restless or fidgety?
| <*Answer_9343*>
|
| 14. How often do you have difficulty unwinding and relaxing when you
| have time to yourself?
| <*Answer_9344*>
|
| SSN: <.Patient_SSN.>
| 15. How often do you find yourself talking too much when you are in
| social situations?
| <*Answer_9345*>
|
| 16. 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_9346*>
|
| 17. How often do you have difficulty waiting your turn in situations
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| when turn taking is required?
| <*Answer_9347*>
|
| 18. How often do you interrupt others when they are busy?
| <*Answer_9348*>
|
|
|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
|
