Behavior Checklist for Adults
Please fill this form out completely. Select the number that indicates how frequently or how much each item describes you as a child (age 5-12).
Adult's Name
0=Never 1=Rarely 2=Once in a While 3=Often 4=Almost Always
0
1
2
3
4
-
1.) I was easily distracted.
0
1
2
3
4
-
2.) I made careless mistakes or had trouble paying close attention details or make careless to details.
0
1
2
3
4
-
3.) I fidgeted (with my hands or feet) or squirmed in my seat.
0
1
2
3
4
-
4.) I had trouble keeping my attention focused at school or during fun activities.
0
1
2
3
4
-
5.) It was hard for me to sit still for long: I left my seat when I was not supposed to.
0
1
2
3
4
-
6.) I didn't listen when people spoke directly to me.
0
1
2
3
4
-
7.) I felt restless.
0
1
2
3
4
-
8.) I had trouble following through on instructions and failed to finish things I started.
0
1
2
3
4
-
9.) I was noisy and had difficulty doing things quietly.
0
1
2
3
4
-
10.) I had difficulty organizing tasks and activities.
0=Never 1=Rarely 2=Once in a While 3=Often 4=Almost Always
0
1
2
3
4
-
11.) I was always on the go, as if driven by a motor.
0
1
2
3
4
-
12.) I avoided, disliked, or was reluctant to engage in work that requires required sustained mental effort.
0
1
2
3
4
-
13.) I talked too much.
0
1
2
3
4
-
14.) I lost things necessary for tasks or activities (lists, pencils, cell phone, keys, books, tools, etc).
0
1
2
3
4
-
15.) I blurted out answers before questions had been completed.
0
1
2
3
4
-
16.) I had trouble awaiting my turn.
0
1
2
3
4
-
17.) I was forgetful in my daily activities.
0
1
2
3
4
-
18.) I interrupted or intruded on others accidentally.
Checklist By Richard Cowles, PsyD. Designed for the ADHD Center of North Dallas 2009.