FREE ASSESSMENT - ADULTS
Please fill out the following and submit your questionnaire - we will email you the results shortly after we receive your complete form.
Name:
Age:
Email:
Please re-enter your email address:
City:
Phone number:
How severe are your symptoms?
1.
Can't focus/ concentrate for long enough
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
2.
Forgetful
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
3.
Disorganized
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
4.
Procrastinating
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
5.
Impatient and/or getting easily frustrated
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
6.
Difficulties completing tasks
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
7.
Difficulties processing new information
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
8.
Unproductive and/or underachieving
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
9.
Feelings of worry and anxiousness
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
10.
Work better with deadline/ pressure
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
11.
Please mention any other difficulties:
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