Version May 2024
| Name: | Date: | ||||
| Sex (circle one): Male Female | Age: | ||||
| Instructions: | |||||
| How often do you experience each of these problems? Please circle the number next to each item that best describes your behavior DURING THE PAST 6 MONTHS. Please ignore the sections marked "Office Use Only." | |||||
| Section 1 items | Never or rarely | Sometimes | Often | Very often | |
| 1. | Procrastinate or put off doing things until the last minute | 1 | 2 | 3 | 4 |
| 2. | Poor sense of time | 1 | 2 | 3 | 4 |
| 3. | Waste or mismanage my time | 1 | 2 | 3 | 4 |
| 4. | Not prepared on time for work or assigned tasks | 1 | 2 | 3 | 4 |
| 5. | Fail to meet deadlines for assignments | 1 | 2 | 3 | 4 |
| 6. | Have trouble planning ahead or preparing for upcoming events | 1 | 2 | 3 | 4 |
| 7. | Forget to do things I am supposed to do | 1 | 2 | 3 | 4 |
| 8. | Can't seem to accomplish the goals I set for myself | 1 | 2 | 3 | 4 |
| 9. | Late for work or scheduled appointments | 1 | 2 | 3 | 4 |
| 10. | Can't seem to hold in mind things I need to remember to do | 1 | 2 | 3 | 4 |
| 11. | Can't seem to get things done unless there is an immediate deadline | 1 | 2 | 3 | 4 |
| 12. | Have difficulty judging how much time it will take to do something or get somewhere | 1 | 2 | 3 | 4 |
| 13. | Have trouble motivating myself to start work | 1 | 2 | 3 | 4 |
| 14. | Have difficulty motivating myself to stick with my work and get it done | 1 | 2 | 3 | 4 |
| 15. | Not motivated to prepare in advance for things I know I am supposed to do | 1 | 2 | 3 | 4 |
| 16. | Have trouble completing one activity before starting into a new one | 1 | 2 | 3 | 4 |
| 17. | Have trouble doing what I tell myself to do | 1 | 2 | 3 | 4 |
| 18. | Difficulties following through on promises or commitments I may make to others | 1 | 2 | 3 | 4 |
| 19. | Lack self-discipline | 1 | 2 | 3 | 4 |
| 20. | Have difficulty arranging or doing my work by its priority or importance; can't "prioritize" well | 1 | 2 | 3 | 4 |
| 21. | Find it hard to get started or get going on things I need to get done | 1 | 2 | 3 | 4 |
| Office Use Only—Section 1 total score __________ | |||||
| Section 2 items | Never or rarely | Sometimes | Often | Very often | |
| 22. | I do not seem to anticipate the future as much or as well as others | 1 | 2 | 3 | 4 |
| 23. | Can't seem to remember what I previously heard or read about | 1 | 2 | 3 | 4 |
| 24. | I have trouble organizing my thoughts | 1 | 2 | 3 | 4 |
| 25. | When I am shown something complicated to do, I cannot keep the information in mind so as to imitate or do it correctly | 1 | 2 | 3 | 4 |
| 26. | I have trouble considering various options for doing things and weighing their consequences | 1 | 2 | 3 | 4 |
| 27. | Have difficulties saying what I want to say | 1 | 2 | 3 | 4 |
| 28. | Unable to come up with or invent as many solutions to problems as others seem to do | 1 | 2 | 3 | 4 |
| 29. | Find myself at a loss for words when I want to explain something to others | 1 | 2 | 3 | 4 |
| 30. | Have trouble putting my thoughts down in writing as well or as quickly as others | 1 | 2 | 3 | 4 |
| 31. | Feel I am not as creative or inventive as others of my level of intelligence | 1 | 2 | 3 | 4 |
| 32. | In trying to accomplish goals or assignments, I find I am not able to think of as many ways of doing things as others | 1 | 2 | 3 | 4 |
| 33. | Have trouble learning new or complex activities as well as others | 1 | 2 | 3 | 4 |
| 34. | Have difficulty explaining things in their proper order or sequence | 1 | 2 | 3 | 4 |
| 35. | Can't seem to get to the point of my explanations as quickly as others | 1 | 2 | 3 | 4 |
| 36. | Have trouble doing things in their proper order or sequence | 1 | 2 | 3 | 4 |
| 37. | Unable to "think on my feet" or respond as effectively as others to unexpected events | 1 | 2 | 3 | 4 |
| 38. | I am slower than others at solving problems I encounter in my daily life | 1 | 2 | 3 | 4 |
| 39. | Easily distracted by irrelevant events or thoughts when I must concentrate on something | 1 | 2 | 3 | 4 |
| 40. | Not able to comprehend what I read as well as I should be able to do; have to reread material to get its meaning | 1 | 2 | 3 | 4 |
| 41. | Cannot focus my attention on tasks or work as well as others | 1 | 2 | 3 | 4 |
| 42. | Easily confused | 1 | 2 | 3 | 4 |
| 43. | Can't seem to sustain my concentration on reading, paperwork, lectures, or work | 1 | 2 | 3 | 4 |
| 44. | Find it hard to focus on what is important from what is not important when I do things | 1 | 2 | 3 | 4 |
| 45. | I don't seem to process information as quickly or as accurately as others | 1 | 2 | 3 | 4 |
| Office Use Only—Section 2 total score __________ | |||||
| Section 3 items | Never or rarely | Sometimes | Often | Very often | |
| 46. | Find it difficult to tolerate waiting; impatient | 1 | 2 | 3 | 4 |
| 47. | Make decisions impulsively | 1 | 2 | 3 | 4 |
| 48. | Unable to inhibit my reactions or responses to events or others | 1 | 2 | 3 | 4 |
| 49. | Have difficulty stopping my activities or behavior when I should do so | 1 | 2 | 3 | 4 |
| 50. | Have difficulty changing my behavior when I am given feedback about my mistakes | 1 | 2 | 3 | 4 |
| 51. | Make impulsive comments to others | 1 | 2 | 3 | 4 |
| 52. | Likely to do things without considering the consequences for doing them | 1 | 2 | 3 | 4 |
| 53. | Change my plans at the last minute on a whim or last minute impulse | 1 | 2 | 3 | 4 |
| 54. | Fail to consider past relevant events or past personal experiences before responding to situations (I act without thinking) | 1 | 2 | 3 | 4 |
| 55. | Not aware of things I say or do | 1 | 2 | 3 | 4 |
| 56. | Have difficulty being objective about things that affect me | 1 | 2 | 3 | 4 |
| 57. | Find it hard to take other people's perspectives about a problem or situation | 1 | 2 | 3 | 4 |
| 58. | Don't think about or talk things over with myself before doing something | 1 | 2 | 3 | 4 |
| 59. | Trouble following the rules in a situation | 1 | 2 | 3 | 4 |
| 60. | More likely to drive a motor vehicle much faster than others (excessive speeding) | 1 | 2 | 3 | 4 |
| 61. | Have a low tolerance for frustrating situations | 1 | 2 | 3 | 4 |
| 62. | Cannot inhibit my emotions as well as others | 1 | 2 | 3 | 4 |
| 63. | I don't look ahead and think about what the future outcomes will be before I do something ( don't use my foresight) | 1 | 2 | 3 | 4 |
| 64. | I engage in risk taking activities more than others are likely to do | 1 | 2 | 3 | 4 |
| Office Use Only—Section 3 total score __________ | |||||
| Section 4 items | Never or rarely | Sometimes | Often | Very often | |
| 65. | Likely to take short cuts in my work and not do all that I am supposed to do | 1 | 2 | 3 | 4 |
| 66. | Likely to skip out on work early if my work is boring to do | 1 | 2 | 3 | 4 |
| 67. | Do not put as much effort into my work as I should or than others are able to do | 1 | 2 | 3 | 4 |
| 68. | Others tell me I am lazy or unmotivated | 1 | 2 | 3 | 4 |
| 69. | Have to depend on others to help me get my work done | 1 | 2 | 3 | 4 |
| 70. | Things must have an immediate payoff for me or I do not seem to get them done | 1 | 2 | 3 | 4 |
| 71. | Have difficulty resisting the urge to do something fun or more interesting when I am supposed to be working | 1 | 2 | 3 | 4 |
| 72. | Inconsistent in the quality or quantity of my work performance | 1 | 2 | 3 | 4 |
| 73. | Unable to work as well as others without supervision or frequent instruction | 1 | 2 | 3 | 4 |
| 74. | I do not have the willpower or determination that others seem to have | 1 | 2 | 3 | 4 |
| 75. | I am not able to work toward longer term or delayed rewards as well as others | 1 | 2 | 3 | 4 |
| 76. | I cannot resist doing things that produce immediate rewards even if they are not good for me in the long run | 1 | 2 | 3 | 4 |
| Office Use Only—Section 4 total score __________ | |||||
| Section 5 items | Never or rarely | Sometimes | Often | Very often | |
| 77. | Quick to get angry or become upset | 1 | 2 | 3 | 4 |
| 78. | Overreact emotionally | 1 | 2 | 3 | 4 |
| 79. | Easily excitable | 1 | 2 | 3 | 4 |
| 80. | Unable to inhibit showing strong negative or positive emotions | 1 | 2 | 3 | 4 |
| 81. | Have trouble calming myself down once I am emotionally upset | 1 | 2 | 3 | 4 |
| 82. | Cannot seem to regain emotional control and become more reasonable once I am emotional | 1 | 2 | 3 | 4 |
| 83. | Cannot seem to distract myself away from whatever is upsetting me emotionally to help calm me down. I can't refocus my mind to a more positive framework. | 1 | 2 | 3 | 4 |
| 84. | Unable to manage my emotions in order to accomplish my goals successfully or get along well with others | 1 | 2 | 3 | 4 |
| 85. | I remain emotional or upset longer than others | 1 | 2 | 3 | 4 |
| 86. | I find it difficult to walk away from emotionally upsetting encounters with others or leave situations in which I have become very emotional | 1 | 2 | 3 | 4 |
| 87. | I cannot rechannel or redirect my emotions into more positive ways or outlets when I get upset | 1 | 2 | 3 | 4 |
| 88. | I am not able to evaluate an emotionally upsetting event more objectively | 1 | 2 | 3 | 4 |
| 89. | I cannot redefine negative events into more positive viewpoints when I feel strong emotions | 1 | 2 | 3 | 4 |
| Office Use Only—Section 5 total score __________ | |||||
| Office Use Only Total of sections 1 to 5: Total EF summary score __________ | |||||
| Office Use Only Count number of items answered 3 or 4 EF symptom count __________ | |||||
| Office Use Only Add items 1, 6, 14, 16, 24, 49, 50, 55, 60, 65, and 69 ADHD-EF index score | |||||
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