Current Symptoms Self-Report Form

Week of:

Instructions: Please check the response next to each item that best describes your behavior during the past week.

Never or Rarely

Sometimes

Often

Very Often

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Fail to give close attention to details or make careless mistakes in my work Fidget with hands or feet or squirm in seat Have diculty sustaining my attention in tasks or fun activities Leave my seat in situations in which seating is expected Dont listen when spoken to directly Feel restless Dont follow through on instructions and fail to nish work Have diculty engaging in leisure activities or doing fun things quietly Have diculty organizing tasks and activities Feel on the go or driven by a motor Avoid, dislike, or am reluctant to engage in work that requires sustained mental eort Talk excessively Lose things necessary for tasks or activities Blurt out answers before questions have been completed Am easily distracted Have diculty awaiting turn Am forgetful in daily activities Interrupt or intrude on others

From R. A. Barkley & K. R. Murphy (1998), Attention-Decit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press. Reprinted with permission.Mastery

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