0 : No problem
1 : Minor problem
2 : Mild problem
3 : Moderately severe problem
4 : Severe problem
5 : Very severe problem
¹
0
1
2
3
4
5
1
Rating the item for the last 2 weeks:
Hyperactivity / restlessness.
2
Pay attention when doing things.
3
Temper / anger outburst.
4
Problems with alcohol and drugs.
5
Ups and downs in your mood.
6
Organising things.
7
Impulsivity.
8
Tension in relationships.
9
Self-harm.
10
Postponing things.
11
Anxiety problems.
12
Depression problems.
13
Sleep problems.
14
Study/work difficulties.
15
Difficulties in the everyday personal life.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.