ADHD Assessment & Evaluation Form

ADHD Self-Assessment Questionnaire

We are currently recruiting patients from 18 to 65 who are experiencing symptoms of ADHD (attention deficit hyperactivity disorder) to participate in a research study evaluating an investigation medication.

Although you will need a full screening by our medical staff to be accepted into this study, your answers to this questionnaire are important. Please take a moment to answer the following questions and tell us about yourself.

Please enter your zip code:

When were you born? // (MM/DD/YYYY)

What is your gender?

Female

Male

How did you hear about Capital Clinical Research Associates?

TV

Radio

Bus

Website

Web ad

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Tell Us About Your Symptoms

Please let us know which of the following symptoms you may be experiencing. Please check all that apply.

At home, work, or school, I find my mind wandering from tasks that are uninteresting or difficult.

Especially in groups, I find it hard to stay focused on what is being said in conversations.

I am irritable and get upset by minor annoyances.

I say things without thinking and later regret having said them.

My moods have highs and lows.

I have trouble planning in what order to do a series of tasks or activities.

I am more comfortable when moving than when sitting still.

In conversations, I start to answer questions before the questions have been fully asked.

I usually work on more than one project at a time, and fail to finish many of them.

Even when sitting quietly, I am usually moving my hands or feet.

I am unable to stop daydreaming.

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Questions or Comments?

Please enter any questions or comments in the space below.

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Your Contact Information

Please tell us how to get in touch with you:

First Name:
Last Name:
Phone 1:
Phone 2:
Best time to reach you:
E-mail:
Image Verification:

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