Psychotherapy Group in the Village
ADD Diagnostic Questionnaire©

The 90 item self-administered questionnaire below is an expanded version of the 71 item ADD questionnaire developed by Daniel G. Amen, M.D. This questionnaire employs a 4-point agree-disagree scale that is both easier to respond to and statistically more sensitive than the frequency of occurrence scale used in Dr. Amen’s questionnaire. It will help us to identify whether you have one of the six different types of ADD that we treat.

Please complete this entire questionnaire, either for yourself or someone you care about, as honestly as possible. When you’ve finished, press the submit button to have your responses emailed automatically to André A. Moore, Director and Senior Psychotherapist of a Psychotherapy Group in the Village New York City.

Once I receive your completed questionnaire, I’ll analyze your responses to make a complete diagnosis, then contact you to schedule an in depth consultation. If you wish, you can call or email me first:

Office - 212 673 4618
Cell – 646 239 9112
Email: andremoore@mindspring.com

First Name*
Last Name*
Age*
*Occupation*
*Work Phone*
Home Phone*
E-mail*
	* denotes compulsory field

Q1. I get easily distracted:

Q2. I feel I can do anything:

Q3. I’m restless, hyperactive:

Q4. I get violent easily:

Q5. I have blank periods I don’t remember:

Q6. It’s hard to keep my attention on most tasks:

Q7. I have trouble sitting still:

Q8. I think about killing myself:

Q9. I have trouble listening when others are talking:

Q10. I talk fast:

Q11. I worry excessively:

Q12. I get into a rage quickly:

Q13. I’m very moody:

Q14. I’m very aggressive:

Q15. It’s hard for me to follow up on tasks or instructions:

Q16. I’m fidgety, in constant motion with my hands, feet or body:

Q17. I’m super organized:

Q18. I feel my thoughts racing:

Q19. I hear comments as negative when they aren’t:

Q20. I hold grudges:

Q21. I’m sensitive to noise:

Q22. It’s hard to keep organized, either my living space, office, desk, etc.:

Q23. I’m noisy, have a hard time being quiet:

Q24. I’m argumentative, oppositional:

Q25. My frustration builds, explodes, then recedes quickly:

Q26. I always see the dark side of everything:

Q27. I’m sensitive to light:

Q28. I get to places late:

Q29. I feel like I’m driven by a motor:

Q30. I get locked into negative thoughts:

Q31. I feel tired after a rage:

Q32. I’m listless, have low energy:

Q33. I’m sensitive to anything touching my skin:

Q34. I’m in a hurry:

Q35. I talk excessively, can’t shut up:

Q36. I have the same thought over and over again:

Q37. I get easily irritated, have a short fuse:

Q38. I feel spacey, confused, disoriented:

Q39. I’m sensitive to people touching me:

Q40. Tasks take longer than I expect them to:

Q41. I rarely think through my comments or actions before doing them:

Q42. I feel anxious, fearful:

Q43. I tend to be compulsive, driven:

Q44. I feel fearful, panicky for no specific reason:

Q45. I feel isolated:

Q46. People say I’m insensitive to others:

Q47. I turn in projects the last minute:

Q48. I have difficulty waiting my turn:

Q49. I hate change:

Q50. I see shadows and or objects that change shape:

Q51. I feel hopeless:

Q52. I’m rigid, inflexible:

Q53. I lose things:

Q54. I feel high, then low, go up and down like a roller coaster:

Q55. I feel I’ve been places before even though I’ve never been, like déjà vu:

Q56. I demand my own way even when told I can’t have it:

Q57. I make careless mistakes, pay poor attention to detail:

Q58. I interrupt others, butt into conversations, games, etc:

Q59. I have trouble shifting my attention from subject to subject:

Q60. I feel paranoid:

Q61. I feel guilty:

Q62. I’m mean, nasty:

Q63. I’m forgetful:

Q64. I have difficulty seeing options or alternatives:

Q65. I get headaches I can’t explain:

Q66. It’s hard for me to have fun:

Q67. I’m insensitive to people:

Q68. I daydream a lot:

Q69. I hold onto my opinions, don’t listen to others:

Q70. I have abdominal pain I can’t explain:

Q71. I sleep too much:

Q72. I can’t stop talking:

Q73. I complain of being bored:

Q74. I get locked into a course of action regardless of whether it’s good for me:

Q75. I injure or bruise my head:

Q76. It’s hard for me to get enough sleep:

Q77. I get angry:

Q78. I’m unmotivated, lackadaisical:

Q79. I need to have things done a certain way or I get upset:

Q80. When I grew up, people in my family tended to be violent or explosive:

Q81. I feel lousy about myself:

Q82. I’m impulsive:

Q83. I’m tired, sluggish, slow moving:

Q84. People complain that I worry too much:

Q85. I have thoughts of killing people:

Q86. I feel preoccupied, in my own world:

Q87. I surprise people with my behavior:

Q88. I feel spacey:

Q89. I feel helpless:

Q90. I have difficulty remembering things:

A Psychotherapy Group in the Village 2005
160 Bleecker Street, 9C East, New York

Call André Moore at (212) 673-4618 or (646) 239 9112 or
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Psychotherapy Group in the Village ADD Diagnostic Questionnaire©

Psychotherapy Group in the Village
ADD Diagnostic Questionnaire©