
What’s your age?
18-25
26-35
36-45
46-55
56-65
65+

When do you first remember having problems focusing, paying attention, or sitting still?
For as long as I can remember
In recent years
Less than a year
Only in the last few months
Not sure

How do you feel about the following statement?
“When something goes wrong, I tend to think of the worst possible scenario.”

Strongly agree

Somewhat agree

Disagree

Strongly disagree

Do you agree with the following statement?
“I tend to get overwhelmed when I have to do complex tasks which require a lot of organization.”

Strongly agree

Somewhat agree

Disagree

Strongly disagree

How often are you distracted by activity or noise around you?
All the time
Often
Sometimes
Rarely
Never

Do you agree with the following statement?
“It’s difficult for me to pay attention and stay focused during difficult or tedious work.”

Strongly agree

Somewhat agree

Disagree

Strongly disagree

How often do you struggle with sitting still in one place?
All the time
Often
Sometimes
Rarely
Never

How do you feel about the following statement?
“I find it difficult to relax – even when I have plenty of time for myself.”

Strongly agree

Somewhat agree

Disagree

Strongly disagree

How often do you find yourself interrupting others in social situations?
All the time
Quite often
It happens, but rarely
Never

Do you often leave things to the last minute?
Always
Too often for my liking
Occasionally
Rarely
Never

Lots of people suffering from ADHD report the following symptoms – can you relate to any of them?
Choose as many or few options as you like
Lack of motivation
Low self-esteem
Racing thoughts
Difficulty in focusing
Struggling with completing tasks
Forgetting commitments frequently
Chronic lateness
Frequent mood swings
Fidgeting, restless legs, or irritable movement
Other

Where do you struggle with ADHD symptoms the most?
Choose as many or few options as you like
At work
In relationships
At school or while studying
It’s a part of my everyday life
During social outings

How often do you experience symptoms of ADHD?
All the time
Often
Sometimes
Never

Thinking about your mental health, have you ever struggled with any of the following?
Choose as many or few options as you like
Depression
Anxiety
Bipolar disorder
Learning difficulties
Obsessive-Compulsive Disorder
Other

Have you ever been in any of the following situations caused by your impulsive behavior tendencies?
Choose as many or few options as you like
Financial problems
Trouble with the law
Alcohol or substance abuse
Instability inrelationships
Frequent car/motorcycle accidents
Other

What do you want to get out of this journey?
Choose as many or few options as you like
Perform better at work
Become more organized
Better performance at school/with studies
Improve my overall mental health
Improve my focus
Eliminate bad habits
Reduce impulsive behavior
Decrease negative thoughts
Improve my relationships with others
Other

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