ADHD assessment (Wender Utah rating scale)

Please note that these forms are for registered patients of Rivermead Gate Medical Centre only.  Any form received for patients not registered at this Practice will be destroyed.

Date of birth(Required)
Gender(Required)

ADHD assessment questions

For each of the 61 items, check the box that best describes your behaviour:
1. As a child I was active, restless, always on the go(Required)
2. As a child I was afraid of things(Required)
3. As a child I had concentration problems, easily distracted(Required)
4. As a child I was anxious, worrying(Required)
5. As a child I was nervous, fidgety(Required)
6. As a child I was inattentive, daydreaming(Required)
7. As a child I was hot - or short-tempered, low boiling point(Required)
8. As a child I was shy, sensitive(Required)
9. As a child I had temper outbursts, tantrums(Required)
10. As a child I had trouble with stick-to-it-tiveness, not following through. Failing to finish things started(Required)
11. As a child I was stubborn, strong-willed(Required)
12. As a child I was sad or blue, depressed, unhappy(Required)
13. As a child I was incautious, dare-devilish, involved in pranks(Required)
14. As a child I was not getting a kick out of things, dissatisfied with life(Required)
15. As a child I was disobedient with parents, rebellious, sassy(Required)
16. As a child I had a low opinion of myself(Required)
17. As a child I was irritable(Required)
18. As a child I was outgoing, friendly, enjoyed company of people(Required)
19. As a child I was sloppy, disorganized(Required)
20. As a child I was moody, ups and downs(Required)
21. As a child I was angry(Required)
22. As a child I had friends, popular(Required)
23. As a child I was well-organized, tidy, neat(Required)
24. As a child I was acting without thinking, impulsive(Required)
25. As a child I had a tendency to be immature(Required)
26. As a child I had guilty feelings, regretful(Required)
27. As a child I was losing control of myself(Required)
28. As a child I had a tendency to be or act irrational(Required)
29. As a child I was unpopular with other children, didn't keep friends for long, didn't get along with other children(Required)
30. As a child I was poorly coordinated, did not participate in sports(Required)
31. As a child I was afraid of losing control of self(Required)
32. As a child I was well-coordinated, picked first in games(Required)
33. As a child I was tomboyish (for women only)
34. As a child I was running away from home(Required)
35. As a child I was getting into fights(Required)
36. As a child I was teasing other children(Required)
37. As a child I was leader, bossy(Required)
38. As a child I had difficulty getting awake(Required)
39. As a child I was a follower, led around too much(Required)
40. As a child I had trouble seeing things from someone else's point of view(Required)
41. As a child I had trouble with authorities, trouble with school, visits to principal's office(Required)
42. As a child I was in trouble with police, booked convicted(Required)

Medical problems as a child

43. Headaches(Required)
44. Stomachaches(Required)
45. Constipation(Required)
46. Diarrhoea(Required)
47. Food allergies(Required)
48. Other allergies(Required)
49. Bedwetting(Required)

As a child in school

50. As a child in school I was overall a good student, fast(Required)
51. As a child in school I was overall a poor student, slow learner(Required)
52. As a child in school I was slow in learning to read(Required)
53. As a child in school I was a slow reader(Required)
54. As a child in school I had trouble reversing letters(Required)
55. As a child in school I had problems with spelling(Required)
56. As a child in school I had trouble with mathematics or numbers(Required)
57. As a child in school I had bad handwriting(Required)
58. As a child in school I was able to read pretty well but never really enjoyed reading(Required)
59. As a child in school I was not achieving up to potential(Required)
60. As a child in school I was repeating grades(Required)
61. As a child in school I was suspended or expelled(Required)
Total sum of all 61 questions
Sum of 25 questions associated with ADHD
Not for urgent medical help(Required)
Consent(Required)

Date published: 11th March, 2024
Date last updated: 4th July, 2024