Adult ADD

This questionnaire is one of three I have my patients fill out before their first scheduled visit. I then go over the questionnaire with them to verify and explore their answers.  If for some reason, they are not able to complete the questionnaire beforehand, I ask them all the questions in person at the time of the visit, but I find this less efficient, and occasionally some questions get overlooked.

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Below is the Adult ADD History Questionnaire. It can help clinicians gather information about a person’s childhood and adult ADD history including information about bipolar illness and other psychological problems.

If you have plans to be evaluated by a clinician, you might want to print this questionnaire, answer the questions and bring the completed questionnaire to the clinician when you have your evaluation appointment.

Childhood history of ADD
Explain, if necessary
As a child, I…
___had to repeat one or more grades_____________________________________________
___fidgeted a lot, couldn’t sit still__________________________________________________
___was distractible, had a short attention span______________________________________
___had a lot of discipline problems_________________________________________________
___never did as well as I should have in school______________________________________
___was treated for ADD_________________________________________________________

Adult history related to ADD
___I have been diagnosed as having ADD__________________________________________
___I have been treated for ADD___________________________________________________
___I have been given one or more tickets for speeding_________________________________
___I was driving a car when it was totaled___________________________________________
___I have been in one or more “fender benders”_____________________________________
___I think so much that I have trouble getting to sleep_________________________________
___I have had to change jobs often (been fired) _______________________________________
___I have had periods when I overspent_____________________________________________
___I have had periods where I gambled too much_____________________________________
___I have had periods when I was overactive physically_________________________________
___I have had periods when my mind raced__________________________________________
___I need a lot of caffeine to get going at the start of the day___________________________
___I have been hospitalized for a psychiatric disorder__________________________________

Family history
___I believe that a blood relative had/has ADD________________________________________
___A blood relative was given the diagnosis of ADD____________________________________
___A blood relative has taken medication for ADD_____________________________________
___I have a blood relative who has manic-depressive (bipolar) illness______________________