Online Pre Assessment Form Adult ADHD Self-report Scale (ASRS) Name * First Last Name * Last Date of birth * Email * Phone * Street Address Line 1 Street Address Line 2 City or town County Postcode 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? Never Rarely Sometimes Often Very Often 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? Never Rarely Sometimes Often Very Often 3. How often do you have problems remembering appointments or obligations? Never Rarely Sometimes Often Very Often 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? Never Rarely Sometimes Often Very Often 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? Never Rarely Sometimes Often Very Often 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Never Rarely Sometimes Often Very Often Submit If you are human, leave this field blank. 07765 637944 07765 637944
