Healing ADD Brain Type Questionnaire
published 7/20/2019Fields 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 *
- 1
- 2
- 3
- 4
2. Difficulty sustaining attention span for most tasks in play, school, or work *
- 1
- 2
- 3
- 4
3. Trouble listening when others are talking *
- 1
- 2
- 3
- 4
4. Difficulty following through (procrastination) on tasks or instructions *
- 1
- 2
- 3
- 4
5. Difficulty keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.) *
- 1
- 2
- 3
- 4
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 *
- 1
- 2
- 3
- 4
7. Tendency to lose things *
- 1
- 2
- 3
- 4
8. Makes careless mistakes, poor attention to detail *
- 1
- 2
- 3
- 4
9. Forgetful *
- 1
- 2
- 3
- 4
10. Restless or hyperactive *
- 1
- 2
- 3
- 4
11. Trouble sitting still *
- 1
- 2
- 3
- 4
12. Fidgety, constant motion (hands, feet, body) *
- 1
- 2
- 3
- 4
13. Noisy, hard time being quiet *
- 1
- 2
- 3
- 4
14. Acts as if "driven by a motor" *
- 1
- 2
- 3
- 4
15. Talks excessively *
- 1
- 2
- 3
- 4
16. Impulsive (doesn’t think through comments or actions before they are said or done) *
- 1
- 2
- 3
- 4
17. Difficulty waiting for turn *
- 1
- 2
- 3
- 4
18. Interrupts or intrudes on others (e.g., butts into conversations or games) *
- 1
- 2
- 3
- 4
19. Excessive or senseless worrying *
- 1
- 2
- 3
- 4
20. Super organized *
- 1
- 2
- 3
- 4
21. Oppositional, argumentative *
- 1
- 2
- 3
- 4
22. Strong tendency to get locked into negative thoughts, having the same thought over and over *
- 1
- 2
- 3
- 4
23. Tendency toward compulsive behavior *
- 1
- 2
- 3
- 4
24. Intense dislike for change *
- 1
- 2
- 3
- 4
25. Tendency to hold grudges *
- 1
- 2
- 3
- 4
26. Trouble shifting attention from subject to subject *
- 1
- 2
- 3
- 4
27. Difficulty seeing options in situations *
- 1
- 2
- 3
- 4
28. Tendency to hold onto own opinion and not listen to others *
- 1
- 2
- 3
- 4
29. Tendency to get locked into a course of action, whether or not it is good for the person *
- 1
- 2
- 3
- 4
30. Need to have things done a certain way or you become very upset *
- 1
- 2
- 3
- 4
31. Others complain that they worry too much *
- 1
- 2
- 3
- 4
32. Periods of quick temper or rage with little provocation *
- 1
- 2
- 3
- 4
33. Misinterprets comments as negative when they are not *
- 1
- 2
- 3
- 4
34. Irritability tends to build, then explodes, then recedes, often tired after a rage *
- 1
- 2
- 3
- 4
35. Periods of spaciness or confusion *
- 1
- 2
- 3
- 4
36. Periods of panic and/or fear for no specific reason *
- 1
- 2
- 3
- 4
37. Visual changes, such as seeing shadows or objects changing shape *
- 1
- 2
- 3
- 4
38. Frequent periods of déjà vu (feelings of being somewhere before even though you never have) *
- 1
- 2
- 3
- 4
39. Sensitivity or mild paranoia *
- 1
- 2
- 3
- 4
40. Headaches or abdominal pain of uncertain origin *
- 1
- 2
- 3
- 4
41. History of a head injury *
- 1
- 2
- 3
- 4
42. Dark thoughts, may involve suicidal or homicidal thoughts *
- 1
- 2
- 3
- 4
43. Periods of forgetfulness or memory problems *
- 1
- 2
- 3
- 4
44. Short fuse or periods of extreme irritability *
- 1
- 2
- 3
- 4
45. Moodiness *
- 1
- 2
- 3
- 4
46. Negativity *
- 1
- 2
- 3
- 4
47. Low energy *
- 1
- 2
- 3
- 4
48. Frequent irritability *
- 1
- 2
- 3
- 4
49. Tendency to be socially isolated *
- 1
- 2
- 3
- 4
50. Frequent feelings of hopelessness, helplessness, or excessive guilt *
- 1
- 2
- 3
- 4
51. Lowered interest in things that are usually considered fun *
- 1
- 2
- 3
- 4
52. Sleep changes (too much or too little) *
- 1
- 2
- 3
- 4
53. Chronic low self-esteem *
- 1
- 2
- 3
- 4
54. Angry or aggressive *
- 1
- 2
- 3
- 4
55. Sensitive to noise, light, clothes, or touch *
- 1
- 2
- 3
- 4
56. Frequent or cyclic mood changes (highs and lows) *
- 1
- 2
- 3
- 4
57. Inflexible, rigid in thinking *
- 1
- 2
- 3
- 4
58. Demanding to have their way, even when told no multiple times *
- 1
- 2
- 3
- 4
59. Periods of mean, nasty, or insensitive behavior *
- 1
- 2
- 3
- 4
60. Periods of increased talkativeness *
- 1
- 2
- 3
- 4
61. Periods of increased impulsivity *
- 1
- 2
- 3
- 4
62. Unpredictable behavior *
- 1
- 2
- 3
- 4
63. Grandiose or “larger than life” thinking *
- 1
- 2
- 3
- 4
64. Appears anxious or fearful *
- 1
- 2
- 3
- 4
65. Predicts the worst *
- 1
- 2
- 3
- 4
66. Freezes in social situation *
- 1
- 2
- 3
- 4
67. Physical stress symptoms, like headaches or excessive muscle tension *
- 1
- 2
- 3
- 4
68. Conflict avoidant *
- 1
- 2
- 3
- 4
69. Fear of being judged *
- 1
- 2
- 3
- 4
70. Excessive motivation *
- 1
- 2
- 3
- 4
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
tags: