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  • Create Date December 27, 2022
  • Last Updated November 10, 2023

Adult ADHD Self-Report Scale

This Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

The questions in this checklist are designed to stimulate dialogue between the physician and their patient and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD).

The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for ASRS v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions.


There are 3 versions to choose from:

  • version includes a button to save form response as HTML and also auto calculates the score.
    • Stan Hurwitz implemented encryption functionality so patients can fill the form and download the encrypted HTML to email back to the clinic of the filled out version. EmailDecrypt.html is the decryption file and the patient's chart number is the default password.
  • only include checkboxes with no automatic calculation.
  • version is simply an HTML-only version which has auto calculation.

Attached Files

ADHD_Adult_Smart_form_with_save_html_and_auto_calculate.zipDownload — Updated on 2022-12-26Download