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Park Medical Centre > Forms > Health Review Forms > ADHD Screening Pack

ADHD Screening Pack

NHS Mental Health Services provision for patients with ADHD is extremely limited. 

In South East London, patients wait an average of 2-3 years for an assessment for diagnosis. Referrals are only accepted for severe cases which fulfil strict criteria and where other alternative mental health diagnosis have been excluded.

 In order to help us to identify whether you are eligible, please complete the following questionnaires, describing as well as you can when difficulties were first noticed, and their impact in your life both in the past and currently.

ADHD Pack

About You

Please use format day/month/year e.g. 12/05/1979
Are you studying now?
Are you in employment / Self Employed

Your Health

Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?

Patient Health Questionnaire-9

Your Mental Health Review

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Generalised Anxiety Disorder 7-item (GAD-7) scale

Over the past 2 weeks how often have you been feeling bothered by the following problems?

1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it’s hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen
Automatically calculated
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Please choose one

Adult ADHD Self-Report Scale Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.

Part A

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organisation?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B

7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn-taking is required?
18. How often do you interrupt others when they are busy?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.