Healing ADD Brain Type Questionnaire

Fields marked with an * are requiredFirst name of person filling out questionnaire *First initial of last name *First name of child for this questionnaire *Email *Email ConfirmationAge of child *

• 0-6
• 6-12
• 12-16
• 16-18

Please rate child on each of the symptoms listed below using the following scale: 1 Rarely, 2 Occasionally, 3 Frequently, 4 Very Frequently. If possible, to give yourself the most complete picture, have another person (such as a teacher or another parent) rate the child by submitting a separate questionnaire. Please note your relation to child in the box below. *1. Easily Distracted *

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2. Difficulty sustaining attention span for most tasks in play, school, or work *

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3. Trouble listening when others are talking *

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4. Difficulty following through (procrastination) on tasks or instructions *

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5. Difficulty keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.) *

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6. Trouble with time, for example, frequently late or hurried, tasks take longer than expected, projects or homework are “last minute” or turned in late *

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7. Tendency to lose things *

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8. Makes careless mistakes, poor attention to detail *

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9. Forgetful *

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10. Restless or hyperactive *

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11. Trouble sitting still *

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12. Fidgety, constant motion (hands, feet, body) *

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13. Noisy, hard time being quiet *

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14. Acts as if "driven by a motor" *

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15. Talks excessively *

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16. Impulsive (doesn’t think through comments or actions before they are said or done) *

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17. Difficulty waiting for turn *

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18. Interrupts or intrudes on others (e.g., butts into conversations or games) *

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19. Excessive or senseless worrying *

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20. Super organized *

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21. Oppositional, argumentative *

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22. Strong tendency to get locked into negative thoughts, having the same thought over and over *

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23. Tendency toward compulsive behavior *

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24. Intense dislike for change *

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25. Tendency to hold grudges *

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26. Trouble shifting attention from subject to subject *

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27. Difficulty seeing options in situations *

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28. Tendency to hold onto own opinion and not listen to others *

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29. Tendency to get locked into a course of action, whether or not it is good for the person *

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30. Need to have things done a certain way or you become very upset *

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31. Others complain that they worry too much *

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32. Periods of quick temper or rage with little provocation *

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33. Misinterprets comments as negative when they are not *

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34. Irritability tends to build, then explodes, then recedes, often tired after a rage *

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35. Periods of spaciness or confusion *

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36. Periods of panic and/or fear for no specific reason *

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37. Visual changes, such as seeing shadows or objects changing shape *

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38. Frequent periods of déjà vu (feelings of being somewhere before even though you never have) *

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39. Sensitivity or mild paranoia *

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40. Headaches or abdominal pain of uncertain origin *

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41. History of a head injury *

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42. Dark thoughts, may involve suicidal or homicidal thoughts *

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43. Periods of forgetfulness or memory problems *

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44. Short fuse or periods of extreme irritability *

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45. Moodiness *

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46. Negativity *

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47. Low energy *

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48. Frequent irritability *

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49. Tendency to be socially isolated *

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50. Frequent feelings of hopelessness, helplessness, or excessive guilt *

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51. Lowered interest in things that are usually considered fun *

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52. Sleep changes (too much or too little) *

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53. Chronic low self-esteem *

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54. Angry or aggressive *

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55. Sensitive to noise, light, clothes, or touch *

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56. Frequent or cyclic mood changes (highs and lows) *

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57. Inflexible, rigid in thinking *

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58. Demanding to have their way, even when told no multiple times *

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59. Periods of mean, nasty, or insensitive behavior *

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60. Periods of increased talkativeness *

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61. Periods of increased impulsivity *

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62. Unpredictable behavior *

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63. Grandiose or “larger than life” thinking *

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64. Appears anxious or fearful *

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65. Predicts the worst *

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66. Freezes in social situation *

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67. Physical stress symptoms, like headaches or excessive muscle tension *

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68. Conflict avoidant *

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69. Fear of being judged *

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70. Excessive motivation *

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If you feel your answers are complete, click the button below to submit your questionnaire. You will receive an email with your results once a member of our team has reviewed your questionnaire.

Submit Questionnaire

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