martel.as.uky.edu

Main menu

Home
Lab Visit
Morning Daily Log
- Current Status Update Form (Morning Daily)
Evening Daily Log
Days 1, 7, 14, 21, 28, 31, & 38
- Brief-A (Certain Days)
Final Visit
Screening and Medical History Form
Second Reporter Form

User login

Username *

Password *

Request new password

Current Symptoms Scale: Self- report for Visit 1

Screening Visit

Screening

Submitted by Lab on Mon, 03/18/2013 - 11:06

Instructions: Please choose the number next to each item that best describes your behavior during the past 6 months. Indicate using 0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

1. Fail to give close attention to details or make careless mistakes in my work (e.g. overlook or miss details, my work is inaccurate). *

2. Fidget with or tap hands or feet or squirm in seat. *

3. Have difficulty sustaining my attention in tasks or fun activities. *

4. Leave my seat in situations in which seating is expected. *

5. Don't listen when spoken to directly. *

6. Feel restless. *

7. Don't follow through on instructions and fail to finish work. *

8. Have difficulty engaging in leisure activities or doing fun things quietly. *

9. Have difficulty organizing tasks and activities. *

10. Feel "on the go" or "driven by a motor." *

11. Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort. *

12. Talk Excessively. *

13. Often lose things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones.) *

14. Often blurt out an answer before a question has been completed (e.g. complete people's sentences and "jump the gun" in conversations, cannot wait for next turn in conversations). *

15. Often easily distracted by extraneous stimuli (or unrelated thoughts). *

16. Often have difficulty waiting for turn (e.g. while waiting in line). *

17. Often forgetful in daily activities (e.g. chores, running errands, returning calls, paying bills, keeping appointments). *

18. Often interrupts or intrudes on others (e.g. butts into conversations, games, or activities; may start using other people's things without asking or receiving permission, intrude into or take over what others are doing). *

How old were you when these problems with attention, impulsiveness, or hyperactivity first began to occur? *

If you do not have any of these, please say so.

To what extent do the problems you just circled interfere with your ability to function in each of these areas of life activities?

0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

In my home life with my immediate family *

In my work or occupation *

In my social interactions with others *

In my activities or dealings in the community *

In any educational activities *

In my dating and marital relationships *

In my management of my money *

In my driving of a motor vehicle *

In my leisure or recreational activities *

In my management of my daily responsibilities *

Instructions: Again, please choose the number next to each item that best describes your behavior during the past 6 months.

0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

1. Lose temper *

2. Argue *

3. Actively defy or refuse to comply with requests or rules *

4. Deliberately annoy people *

5. Blame others for my mistakes or misbehavior *

6. Am touchy or easily annoyed by others *

7. Am angry or resentful *

8. Am spiteful or vindictive *

Main menu

User login

You are here

Current Symptoms Scale: Self- report for Visit 1

Screening Visit