ADHD Childhood Symptoms Questionnaire

The original Wender Utah Rating Scale is 61 questions. This version represents the 25 questions most associated with ADHD.

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, select the option that best describes how you have felt and conducted yourself over the past 6 months.

Name *

First

Last

Email *

Date / Time

Date

Time

As a child I was (or had):

1. Concentration problems, easily distracted *

2. Nervous, fidgety *

3. Hot- or short-tempered,low-boiling point *

4. Trouble with stick-to-it-tiveness, not following through, *

5. Disobedient with parents, rebellious,sassy *

6. Low opinion of myself *

7. Angry *

8. Acting without thinking, impulsive *

9. Tendency to be or act irrational *

10. Unpopular with other children,didn't keep friends for long, didn't get along with other children *

11. Trouble seeing things from someone else's point of view *

12. Trouble with authorities, trouble with school, visits to principal's office (copy) *

As a child I was (or had):

13. Overall a poor student, a slow learner *

14. Trouble with mathematics or numbers *

15. Not achieving up to potential *

References

Ward MF W ender PH Reimherr FW.
The W ender Utah Rating Scale: An aid in the retrospective diagnosis of childhood Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 1993; 150: 885-890.