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Healing ADD Brain Type Questionnaire

published 7/20/2019

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 *

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 *

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

3. Trouble listening when others are talking *

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

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

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 *

7. Tendency to lose things *

8. Makes careless mistakes, poor attention to detail *

9. Forgetful *

10. Restless or hyperactive *

11. Trouble sitting still *

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

13. Noisy, hard time being quiet *

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

15. Talks excessively *

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

17. Difficulty waiting for turn *

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

19. Excessive or senseless worrying *

20. Super organized *

21. Oppositional, argumentative *

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

23. Tendency toward compulsive behavior *

24. Intense dislike for change *

25. Tendency to hold grudges *

26. Trouble shifting attention from subject to subject *

27. Difficulty seeing options in situations *

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

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

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

31. Others complain that they worry too much *

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

33. Misinterprets comments as negative when they are not *

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

35. Periods of spaciness or confusion *

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

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

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

39. Sensitivity or mild paranoia *

40. Headaches or abdominal pain of uncertain origin *

41. History of a head injury *

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

43. Periods of forgetfulness or memory problems *

44. Short fuse or periods of extreme irritability *

45. Moodiness *

46. Negativity *

47. Low energy *

48. Frequent irritability *

49. Tendency to be socially isolated *

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

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

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

53. Chronic low self-esteem *

54. Angry or aggressive *

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

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

57. Inflexible, rigid in thinking *

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

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

60. Periods of increased talkativeness *

61. Periods of increased impulsivity *

62. Unpredictable behavior *

63. Grandiose or “larger than life” thinking *

64. Appears anxious or fearful *

65. Predicts the worst *

66. Freezes in social situation *

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

68. Conflict avoidant *

69. Fear of being judged *

70. Excessive motivation *

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