ADULT ADHD SELF-REPORT SCALE ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST Step 1 of 2 50% ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLISTPatient:(Required)Date Completed(Required) MM slash DD slash YYYY Phone(Required)Email(Required) 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, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during your appointment. The CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)Have you felt you ought to cut down on your drinking or drug use?(Required) Yes No Have people annoyed you by criticizing your drinking or drug use?(Required) Yes No Have you felt bad or guilty about your drinking or drug use?(Required) Yes No Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?(Required) Yes No 2/4 or greater = positive CAGE, further evaluation is indicated Δ Adult ADHD Self-Report Scale | Clearwater Aesthetics IV Infusion Booking Form Add Your Heading Text Here