ASRS v1.1 SCREEN

Date: [Date]
Patient: [Name or ID, age]
Completed by: [Patient on paper, patient online, or items read aloud word for word; interpreter if used]
Reason for screening: [Concentration or organization concerns, referral question, or routine screening]
Form used: [6-question screener only, or the full 18-item checklist]

PART A SCREEN
Answers in the shaded range: [Number of the 6 Part A answers in the shaded boxes]
Shaded items: [Which of items 1 to 6]
Screen result: [Positive at 4 or more of 6, or negative at 0 to 3]
Sum score, if used: [Part A total 0 to 24, cutoff 14; say which method the service uses]

PART B
Part B notes: [Shaded answers among items 7 to 18, the symptom areas they point to, and examples the patient gave]

COLLATERAL AND CONTEXT
Collateral information: [Who was asked, with consent, and what they said about childhood and daily life now]
Childhood evidence: [School reports or other records, or none available]
Other explanations: [Mood, anxiety, sleep, substance use, medicines, medical causes; other screening scores]

NEXT STEP
Decision: [Full adult ADHD assessment, treat another condition first and repeat the screen, or no further action]
Referral: [To whom, and what was sent]
Repeat screen: [Date, or the change that would prompt it]

Clinician: [Name, credentials]