"Adult Self-report Symptom Checklist Template"

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Subject’s Name ____________________________________________Date _________________________
Completed by ___________________________________ Relationship to Subject ______________________
Circle the number that best describes the person
Makes careless mistakes when working on a boring or difficult project
0
1
2
3
4
Has difficulty staying attentive when doing boring or repetitive work
0
1
2
3
4
Has difficulty concentrating on what people are saying, even when being
0
1
2
3
4
spoken to directly
Has trouble wrapping up the final details of a project, once the challenging
0
1
2
3
4
parts have been done
Has difficulty getting things in order when the task requires organization
0
1
2
3
4
Avoids or delays getting started on tasks or projects that require a lot of
0
1
2
3
4
thought or organization
Misplaces or has difficulty findings things at home or at work
0
1
2
3
4
Is distracted by surrounding activity or noise
0
1
2
3
4
Has problems remembering appointments or obligations
0
1
2
3
4
Fidgets with hands, feet or objects when having to sit for a long time
0
1
2
3
4
Leaves seat in meetings or other situations in which one is expected to
0
1
2
3
4
remain seated
Feels restless or fidgety
0
1
2
3
4
Has difficulty unwinding and relaxing when one has time to oneself
0
1
2
3
4
Feels overly active and compelled to do things, like being driven by a
0
1
2
3
4
motor
Finds oneself talking too much when in a social situation
0
1
2
3
4
When in a conversation, finishes the sentence of the other person before
0
1
2
3
4
they can finish it them themselves
Has difficulty waiting one’s turn in situations when patience is required
0
1
2
3
4
Interrupts others when the other person is busy
0
1
2
3
4
Please turn to side 2
Vanderbilt Behavioral Questionnaire-Adult Version is adapted from
Adult Self-Report Symptom Checklist copyright ©2003 World Health Organization
and The Vanderbilt Assessment Scales by Mark L. Wolraich, MD
Subject’s Name ____________________________________________Date _________________________
Completed by ___________________________________ Relationship to Subject ______________________
Circle the number that best describes the person
Makes careless mistakes when working on a boring or difficult project
0
1
2
3
4
Has difficulty staying attentive when doing boring or repetitive work
0
1
2
3
4
Has difficulty concentrating on what people are saying, even when being
0
1
2
3
4
spoken to directly
Has trouble wrapping up the final details of a project, once the challenging
0
1
2
3
4
parts have been done
Has difficulty getting things in order when the task requires organization
0
1
2
3
4
Avoids or delays getting started on tasks or projects that require a lot of
0
1
2
3
4
thought or organization
Misplaces or has difficulty findings things at home or at work
0
1
2
3
4
Is distracted by surrounding activity or noise
0
1
2
3
4
Has problems remembering appointments or obligations
0
1
2
3
4
Fidgets with hands, feet or objects when having to sit for a long time
0
1
2
3
4
Leaves seat in meetings or other situations in which one is expected to
0
1
2
3
4
remain seated
Feels restless or fidgety
0
1
2
3
4
Has difficulty unwinding and relaxing when one has time to oneself
0
1
2
3
4
Feels overly active and compelled to do things, like being driven by a
0
1
2
3
4
motor
Finds oneself talking too much when in a social situation
0
1
2
3
4
When in a conversation, finishes the sentence of the other person before
0
1
2
3
4
they can finish it them themselves
Has difficulty waiting one’s turn in situations when patience is required
0
1
2
3
4
Interrupts others when the other person is busy
0
1
2
3
4
Please turn to side 2
Vanderbilt Behavioral Questionnaire-Adult Version is adapted from
Adult Self-Report Symptom Checklist copyright ©2003 World Health Organization
and The Vanderbilt Assessment Scales by Mark L. Wolraich, MD
Just a
Very
Never
Often
little
often
Gets in arguments with other adults
0
1
2
3
Loses temper
0
1
2
3
Actively defies or refuses to go along with adult requests or
0
1
2
3
rules
Deliberately annoys people
0
1
2
3
Blames others for his/her mistakes or misbehaviors
0
1
2
3
Is touchy or easily annoyed by others
0
1
2
3
Is angry or resentful
0
1
2
3
Is spiteful and wants to get even
0
1
2
3
Is fearful, anxious or worried
0
1
2
3
Is afraid to try new things for fear of making mistakes
0
1
2
3
Feels worthless or inferior
0
1
2
3
Blames self for problems, feels guilty
0
1
2
3
Feels lonely, unwanted, or unloved
0
1
2
3
Is sad, unhappy or depressed
0
1
2
3
Is self-conscious or easily embarrassed
0
1
2
3
Some-
Above
Excellent
Average
what a
A problem
Average
problem
Overall academic/work/career
0
1
2
3
4
performance
Reading
0
1
2
3
4
Mathematics
0
1
2
3
4
Written Expression
0
1
2
3
4
Effort
0
1
2
3
4
Academic achievement/career
0
1
2
3
4
advancement
Assignment/task completion
0
1
2
3
4
Overall family & social functioning
0
1
2
3
4
Relationship with spouse or
0
1
2
3
4
significant other
Relationship with parents, children,
0
1
2
3
4
relatives
Interpersonal (friendship)
0
1
2
3
4
relationships
Participation in organized activities
0
1
2
3
4
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