Healthcare ADHD Rating Scale

HEALTHCARE ADHD RATING SCALE

Patient Information

Date of Birth:   Gender: Select Female Male Non-binary Prefer not to say Other

Insurance Information

Medical History

ADHD Rating Instructions

Please rate the frequency of the following behaviors over the past six months using the scale below. Enter a single number (0–3) in the score field for each item.

0 = Never or Rarely    1 = Occasionally    2 = Often    3 = Very Often

Inattention Symptoms (Rate 0–3)

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities. Score:

2. Often has difficulty sustaining attention in tasks or play activities. Score:

3. Often does not seem to listen when spoken to directly. Score:

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace. Score:

5. Often has difficulty organizing tasks and activities. Score:

6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort. Score:

7. Often loses things necessary for tasks or activities (e.g., keys, paperwork, eyeglasses). Score:

8. Is often easily distracted by extraneous stimuli. Score:

9. Often forgetful in daily activities. Score:

Hyperactivity / Impulsivity Symptoms (Rate 0–3)

10. Often fidgets with or taps hands or feet or squirms in seat. Score:

11. Often leaves seat in situations when remaining seated is expected. Score:

12. Often runs about or climbs in situations where it is inappropriate (adolescents or adults may feel restless). Score:

13. Often unable to play or engage in leisure activities quietly. Score:

14. Is often "on the go," acting as if "driven by a motor." Score:

15. Often talks excessively. Score:

16. Often blurts out answers before questions have been completed. Score:

17. Often has difficulty waiting his or her turn. Score:

18. Often interrupts or intrudes on others (e.g., butts into conversations or games). Score:

Functional Impairment and History

Do the symptoms cause significant impairment in social, academic, or occupational functioning? Select No Mild Moderate Severe

Scoring Summary (enter numeric totals)

Scoring note: Totals are used as a standardized screening metric. A comprehensive diagnostic determination must include clinical interview, collateral information, and consideration of medical and psychiatric history.

Privacy Acknowledgment and Authorization

The information provided on this form is confidential and will be used for clinical assessment and treatment planning. By signing below, I acknowledge that I have been informed about the use of this health information for assessment purposes and authorize the clinic to use and disclose this limited information to other healthcare providers involved in evaluation or treatment as necessary.

Authorization expiration (if not otherwise specified):

I understand that completion of this rating scale is a component of clinical assessment and does not alone constitute a diagnosis. I certify that the information I have provided on this form is true and complete to the best of my knowledge.

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