Adult Survey

Your Name (required)

I would to schedule the consultation in the:

Your Email (required)

Phone (required)

What is your age?

Do you currently hold a job?

Are you currently enrolled in any college courses?

Attention Stamina

Does your attention seem to be scattered?

Do you have difficulty directing your attention?

Do you have difficulty sustaining attention to a single task for longer than a few minutes?

Visual Tracking

When in a conference or work meeting environment, do you pay attention only when the presenter is in close proximity (standing over you)?

Do you lose attention quickly once that person has moved out of proximity?

Do you have difficulty participating in a sport and sustaining attention to your required task?

Do you lose interest unless what your viewing is highly visually stimulating?

Time On Task

Do you have difficulty completing tasks?

Do you often fail to pay close attention to details or make careless mistakes in housework, office work, or other activities?

Do you frequently have difficulty sustaining attention during tasks or recreational activities?

Do you avoid or become resistant to engage in tasks that require sustained mental effort like homework, balancing your checkbook, or office work?

When you are working on an assignment independently, do you need constant redirection?

Short Term Memory

Do you have difficulty following multiple commands?

Do you frequently need to have instructions repeated?

Do you have difficulty memorizing names, facts or dates?

Discriminatory Processing

Are you often easily distracted by extraneous stimuli?

When trying to focus on a task, are you easily distracted by background noises?

When trying to focus on a task, are you easily distracted by visual distractions such as movement?

Spatial Memory

Do you constantly lose things?

Do you have difficulty organizing materials for school or work?

Do you often loose work assignments?

Working Memory

Do you often lose your train of thought?

Do you have difficulty solving mathematical calculations in your head?

Do you have difficulty reasoning or evaluating situations?

Social Skills

Do you have difficulty making friends?

Do you have difficulty adjusting your behavior in a group setting?

Do you have difficulty making eye contact?

Do you often interrupt conversations?

Do you have difficulty taking turns?

Do you often have conflicts with your peers, spouse, or siblings?

Has your attention difficulty affected your relationships in a negative way?

Motor Skills

Do you seem to break things often?

Do you have poor handwriting?

Do you seem to have more accidents, bruises and scrapes than your peers?


Do you frequently lose things?

Do you have difficulty organizing tasks and activities?

Do you require assistance from someone else to complete a project?

Do you have difficulty managing time?


Do you exhibit behaviors that impede your performance?

Do you frequently fidget with your hands or feet or squirm in your seat?

Do you often leave your seat in situations in which remaining seated is expected?

Do you often move about excessively in situations in which it is inappropriate? (In adolescents or adults may be limited to subjective feelings of restlessness.)

Do you often have difficulty engaging in leisure activities quietly?

Do you often appear to be "on the go" or often act as if "driven by a motor?"

Do you often talk excessively?

Do you often blurt out answers before questions have been completed?

Do you often intrude on others at work or at home?

Have you experienced job loss due to your attention problem?

In your opinion, what are the top 3 skills you need to improve?

Other notes or comments

Thank you for submitting this survey. One of our specialists will contact you shortly to confirm your appointment time.

We will also email you a copy of the completed survey.

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