About this template
The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist is a validated screening instrument used by healthcare professionals, therapists, and counselors to evaluate the presence and frequency of adult ADHD symptoms. This standardized tool helps clinicians gather critical self-reported behavioral insights before or during initial clinical evaluations.
Doc2Form makes it simple to deploy this assessment digitally as a Google Form. Patients or clients can complete the checklist securely from any device, rating their recent experiences with attention, organization, hyperactivity, and restlessness. Using Doc2Form, clinicians can rapidly generate a structured questionnaire that feeds directly into their workflow, streamlining patient intake and supporting more accurate clinical conversations.
Key features
- Standardized ASRS-v1.1 symptom frequency questions in an easy-to-read layout
- Collect patient demographic details and contact info alongside symptom metrics
- Mobile-friendly format for seamless completion on smartphones, tablets, or computers
- Automatically organize responses in Google Sheets for quick review prior to sessions
- Easily customizable to match your clinic's branding and intake requirements
Use cases
- Initial mental health intake and psychological evaluation appointments
- Pre-screening patients for adult ADHD before diagnostic consultations
- Tracking symptom severity and treatment progress over time in therapy
- Remote client assessment for telehealth and virtual counseling practices
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth.
- Date Completed (Date)Today's date.
- Email Address (Short answer)Where can we reach you if needed?
- 1. How often do you make careless mistakes when you have to work on a boring or difficult project? (Multiple choice)Select the option that best describes your experience over the past 6 months.
- 2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? (Multiple choice)Consider tasks like data entry, paperwork, or routine chores.
- 3. How often do you have difficulty concentrating on what people are saying to you, even when they are speaking directly to you? (Multiple choice)Think about conversations in meetings, lectures, or one-on-one chats.
- 4. How often do you misplace or have difficulty finding things at home or at work? (Multiple choice)Consider items such as keys, glasses, wallet, paperwork, or phone.
- 5. How often are you distracted by activity or noise around you? (Multiple choice)Think about open offices, background sounds, or visual distractions.
- 6. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? (Multiple choice)Reflect on work settings, classrooms, or formal gatherings.
- 7. How often do you feel restless or fidgety? (Multiple choice)Consider tapping hands or feet, or feeling an internal sense of restlessness.
- 8. How often do you have difficulty unwinding and relaxing when you have time to yourself? (Multiple choice)Think about evenings, weekends, or downtime periods.
- Additional Context & Comments (Paragraph)Share any additional information, specific challenges, or context you would like your clinician to review.
FAQ
How do I share this form with my patients?
Once generated in Google Forms, you can share the form via a direct link, email it to clients before their appointment, or embed it securely on your practice's website.
Where are the patient responses saved?
All submissions are automatically stored in a secure Google Sheet connected to your Google Form, allowing you to review scores and answers in real time.
Can I customize the questions or add my practice logo?
Yes! Because the template is created directly in Google Forms, you have full freedom to edit questions, add your clinic's branding, or adjust settings as needed.
Is this checklist a definitive medical diagnosis?
No, the ASRS-v1.1 is a screening and symptom monitoring tool designed to aid clinical evaluations, not replace a comprehensive professional diagnosis.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.