About this template
The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist is a standardized tool designed to help clinicians and patients identify potential symptoms of Attention Deficit/Hyperactivity Disorder. This digital template streamlines the intake process by allowing patients to complete the assessment remotely before their appointment, ensuring that clinical time is spent discussing results rather than manual data entry.
This form captures the 18 core symptoms of ADHD as defined by the ASRS-v1.1 criteria. By using this Google Form, practitioners can maintain a consistent, organized record of patient responses. It is an essential resource for mental health professionals, therapists, and primary care providers looking to digitize their initial screening process and improve the efficiency of their patient assessments.
Key features
- Standardized ASRS-v1.1 symptom assessment format.
- Streamlines patient intake and pre-appointment screening.
- Easy to share via email or secure patient portal link.
- Organizes responses automatically into a Google Sheet for review.
- Fully customizable to include your practice branding and contact details.
Use cases
- Initial mental health intake assessments.
- Ongoing monitoring of ADHD symptom management.
- Pre-screening for telehealth consultations.
- Clinical research data collection.
What this form collects
- Full Name (Short answer)Please enter your full legal name.
- Date of Birth (Date)Format: MM/DD/YYYY
- How often do you have difficulty wrapping up the final details of a project, once the challenging parts have been done? (Linear scale)Scale: 1 = Never, 5 = Very Often
- How often do you have difficulty getting things in order when you have to do a task that requires organization? (Linear scale)Scale: 1 = Never, 5 = Very Often
- How often do you have problems remembering appointments or obligations? (Linear scale)Scale: 1 = Never, 5 = Very Often
- When you have a task that requires a lot of thought, how often do you avoid or delay getting started? (Linear scale)Scale: 1 = Never, 5 = Very Often
- How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? (Linear scale)Scale: 1 = Never, 5 = Very Often
- How often do you feel overly active and compelled to do things, like you were driven by a motor? (Linear scale)Scale: 1 = Never, 5 = Very Often
- Additional Comments (Paragraph)Please share any additional context regarding your symptoms that you would like your clinician to know.
FAQ
Is this form compliant with medical privacy regulations?
While this template is a functional tool for collecting data, please ensure your Google Workspace account is configured for the appropriate security and compliance standards required by your jurisdiction before collecting sensitive health information.
Can I add my own branding to this form?
Yes. Once you copy this template to your Google Drive, you can use the Google Forms editor to add your practice logo, change the color scheme, and add your clinic's specific contact information.
How do I review the patient's scores?
All responses are automatically saved in the 'Responses' tab of your Google Form. You can also link the form to a Google Sheet to view all patient submissions in a structured spreadsheet format.
Can I modify the questions?
Absolutely. You can edit, add, or remove questions to better suit your clinical workflow or to include additional patient history questions.
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.