Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, select the answer that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today's appointment.
PART A
1. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? Never Rarely Sometimes Often Very Often
2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? Never Rarely Sometimes Often Very Often
3. How often do you have difficulty unwinding and relaxing when you have time to yourself? Never Rarely Sometimes Often Very Often
4. When you are 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? Never Rarely Sometimes Often Very Often
5. How often do you put things off until the last minute? Never Rarely Sometimes Often Very Often
6. How often do you depend on others to keep your life in order and attend to details? Never Rarely Sometimes Often Very Often
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