Behavior Checklist for Adults

Adult's Name

0=Never 1=Rarely 2=Once in a While 3=Often 4=Almost Always

1.) I am easily distracted.

2.) I don’t plan ahead: I’m impulsive.

3.) I make careless mistakes or have trouble paying close attention to details or make careless to details.

4.) I fidget (with my hands or feet) or squirm in my seat.

5.) I have trouble keeping my attention focused at work or during fun activities.

6.) It’s hard for me to sit still for long: I leave my seat when I am not supposed to.

7.) I don't listen when people speak directly to me.

8.) I feel restless.

9.) I have trouble following through on instructions and fail to finish things I started.

10.) I am noisy and have difficulty doing things quietly.

0=Never 1=Rarely 2=Once in a While 3=Often 4=Almost Always

11.) I have difficulty organizing tasks and activities.

12.) I am always on the go, as if driven by a motor.

13.) I avoid, dislike, or am reluctant to engage in work that requires sustained mental effort.

14.) I talk too much.

15.) I lose things necessary for tasks or activities (lists, pencils, cell phone, keys, books, tools, etc).

16.) I blurt out answers before questions have been completed.

17.) I have trouble awaiting my turn.

18.) I am forgetful in my daily activities.

19.) I interrupt or intrude on others accidentally.

20.) I am moody with a lot of ups and downs.

0=Never 1=Rarely 2=Once in a While 3=Often 4=Almost Always

21.) I say things without thinking.

22.) I didn’t achieve up to my potential.

23.) I have a tendency to be immature.

24.) I have feelings of guilt and regret.

25.) I’m not sure of myself.

0=Not at All 2=Somewhat 4=Very Much

26.) As a child I was unpopular, didn’t keep friends long, and didn’t get along with other children.

27.) Overall, I was a poor student or slow learner.

28.) I had trouble with mathematics or numbers in school