ADHD (Attention Deficit Hyperactivity Disorder)

ADHD – Adult

Please complete this form if you think that you may have the condition ADHD. It takes around 20 minutes to complete so we advise you set aside this time in advance of starting the form.

On completion, we will assess your likelihood of ADHD and book you for a GP consultation to discuss it. There are two outcomes:

  1. We do not think you have ADHD. 
  2. You are likely to have ADHD. We will refer you to the Adult Mental Health Team. Unfortunately there is currently a waiting list for this specialty of around 2 years. In the meantime it is recommended you download and read the useful
    ADHD Self Help Resource Pack
Marital Status
A diagnosis of ADHD will not be considered if you drink more than 30 units of alcohol per week or take regular recreational drugs (including cannibis)

Adult ADHD Self-Report Scale (ASRS 1.1 )

Please answer the questions below, rating yourself as best describes how you have felt and conducted yourself over the past 6 months.

Part A

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B

7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
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?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

WEISS Functional Impairment Rating Scale – Self Report (WFIRS-S)

© 2011 Margaret Danielle Weiss

Click the rating that best describes how your emotional or behavioural problems have affected each item in the last month with the exception of your experiences at school.

A. Family

1. Having problems with family
2. Having problems with spouse/partner
3. Relying on others to do things for you
4. Causing fighting in the family
5. Makes it hard for the family to have fun together
6. Problems taking care of the family
7. Problems balancing your needs against those of your family
8. Problems losing control with family

B. Work

1. Problems performing required duties
2. Problems with getting your work done efficiently
3. Problems with your supervisor
4. Problems keeping a job
5. Getting fired from work
6. Problems working in a team
7. Problems with your attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Poor performance evaluations

C. School

1. Problems taking notes
2. Problems completing assignments
3. Problems getting your work done efficiently
4. Problems with teachers
5. Problems with school administrators
6. Problems meeting minimum requirements to stay in school
7. Problems with attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Problems with inconsistent grades

D. Life Skills

1. Excessive or inappropriate use of internet, video games or TV
2. Problems keeping an acceptable appearance
3. Problems getting ready to leave the house
4. Problems getting to bed
5. Problems with nutrition
6. Problems with sex
7. Problems with sleeping
8. Getting hurt or injured
9. Avoiding exercise
10. Problems keeping regular appointments with doctor/dentist
11. Problems keeping up with household chores
12. Problems managing money

E. Self Concept

1. Feeling bad about yourself
2. Feeling frustrated with yourself
3. Feeling discouraged
4. Not feeling happy with your life
5. Feeling incompetent

F. Social

1. Getting into arguments
2. Trouble cooperating
3. Trouble getting along with people
4. Problems having fun with other people
5. Problems participating in hobbies
6. Problems making friends
7. Problems keeping friends
8. Saying inappropriate things
9. Complaints from neighbours

G. Risk

1. Aggressive driving
2. Doing other things while driving
3. Road rage
4. Breaking or damaging things
5. Doing things that are illegal
6. Being involved with the police
7. Smoking cigarettes
8. Smoking Marijuana
9. Drinking alcohol
10. Taking “street drugs”
11. Sex without protection (birth control, condom)
12. Sexually inappropriate behaviour
13. Being physically aggressive
14. Being verbally aggressive

WEISS Scores

You have made it to the end of the form. Well done! On submission we will be in touch with an appointment to discuss with a GP.
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.
© 2022 Kristian Turnbull