The Amen Clinic ADD Type Questionnaire Client:

1 The Amen Clinic ADD Type QuestionnaireClient: _____ 2003 Daniel Amen, : _____Date: ___/___/_____Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using thefollowing scale. 0 Never1 Rarely2 Occasionally3 Frequently4 Very FrequentlyN/A Not easily difficulty sustaining attention span for most tasks in play, school, trouble listening when others are difficulty following through (procrastination) on tasks or difficulty keeping an organized area (room, desk, backpack, filingcabinet, locker, etc.) trouble with time; for example, is frequently late or hurried, tasks takelonger than expected, projects or homework are last-minute or turned a tendency to lose careless mistakes, poor attention to of being apathetic or tired, sluggish, or spacey or seems restless or trouble sitting fidgety, in constant motion (hands, feet, body) noisy, has a hard time being as if driven by a motor FFFFFFPage 2 ADD0 never 1 rarely 2 occasionally 3 frequently 4 very impulsive (doesn t think through comments or actions before they aresaid or done) difficulty waiting his or her or intrudes on others ( , butts into conversations or games) excessively or oppositional, a strong tendency to get locked into negative thoughts.

2 Has the samethought over and a tendency toward compulsive an intense dislike of a tendency to hold trouble shifting attention from subject to difficulties seeing options in a tendency to hold on to own opinion and not listen to a tendency to get locked into a course of action, whether or not it isgood for the to have things done a certain way or becomes very complains that he or she worries too periods of quick temper or rages with little comments as negative when they are tends to build, then explodes, then recedes; is often tired after periods of spaciness or periods of panic and/or fear for no specific visual changes, such as seeing shadows or objects periods of deja vu (feelings of being somewhere before even thoughhe or she has never been there)

3 Sensitive or mildly paranoidFFFFFFPage 30 never 1 rarely 2 occasionally 3 frequently 4 very headaches or abdominal pain of uncertain a history of a head injury or a family history of violence dark thoughts, may involve suicidal or homicidal periods of forgetfulness or memory a short fuse or periods of extreme low frequently a tendency to be socially frequent feelings of helplessness, hopelessness, or excessive lowered interest in things that are usually considered sleep changes (too much or too little) chronic low angry or sensitive to noise, light, clothes or frequent or cyclic mood changes (highs and lows) inflexible, rigid in to have his or her way, even when told no multiple periods of mean, nasty, or insensitive periods of increased periods of increased unpredictable of thinking is grandiose or larger-than-life that thoughts go anxious or fearfulFFFFFFUsed by permission: Amen, MD, Daniel (2002).

4 Healing ADD. New York: Berkeley :\Amen ADD Questionnaire 3