Adult ADHD Self Questionnaire

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Attention Deficit / Hyperactivity Disorder Self Referral for Assessment

We do not make recommendations about which provider is most suitable for you.

You are responsible for doing your own research and assuring yourself that a provider is able to meet your needs.

We have provided a list of current known providers for ease, but this list is not exhaustive. If you would like to use a provider not listed, you will be able to provide their details.

More about the Right To Choose process

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Shared Care Agreements

The Practice will not enter into new Shared Care Agreements for the prescription of ADHD medications proposed after an assessment and diagnosis

ADHD prescribing (and associated monitoring) will be undertaken by a central service currently run by the Suffolk GP Federation.

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Mental Health Declaration

Mental Health Declaration

If you have features of any other mental health condition or are concerned, One example being features of depression such as Thoughts of self-harm, suicidal ideation or plans, drug or substance misuse then please contact the GP practice to discuss these issues separately.

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ADHD Provider

Personal Details

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Part A

Please answer the following questions, rating yourself on each of the criteria shown

For each question, select the answer that best describes how you have felt and conducted yourself over the past 6 months.

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Next Step

Symptoms highly consistent with ADHD

, you have a score of

Your score indicates symptoms highly consistent with ADHD, and further investigation is warranted.

If you would like to send this assessment to the surgery please continue to the next page

The previous questions are the most predictive of ADHD and are best for use as a screening instrument.

However, the frequency scores from the questions on the next page provide additional cues and can serve as further indications of symptoms.

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Part B

Please answer the following questions, rating yourself on each of the criteria shown

For each question, select the answer that best describes how you have felt and conducted yourself over the past 6 months.

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Adult ADHD Self Questionnaire

Attention Deficit / Hyperactivity Disorder Self Referral for Assessment

Shared Care Agreements

Mental Health Declaration

Please answer the following questions, rating yourself on each of the criteria shown

Symptoms highly consistent with ADHD

, you have a score of

Please answer the following questions, rating yourself on each of the criteria shown

Privacy Consent

Contact

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