Do You Suffer From
ADHD or ANXIETY?
ADHD Questionnaire
1. Do you have trouble wrapping up projects once the challenging parts are done? ❑ YES ❑ NO
2. Do you have problems remembering appointments or obligations?
❑ YES ❑ NO
3. Do you fidget or squirm with your hands or feet when you sit down for a long time?
❑ YES ❑ NO
4. Do you make careless mistakes when you work on a boring or difficult project?
❑ YES ❑ NO
5. Are you distracted by activity or noise around you?
❑ YES ❑ NO
6. Do you often misplace or have difficulty finding things at home or work?
❑ YES ❑ NO
7. Do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
❑ YES ❑ NO CLIP HERE & CALL! Anxiety Questionnaire
1. Over the last 2 weeks, how often have you felt nervous, anxious, or on edge? ❑ Not at all
❑ Several days ❑ More than ½ the days ❑ Nearly every day
2. Over the last 2 weeks, how often have you not been able to stop or control worrying?
❑ Not at all ❑ Several days
❑ More than ½ the days ❑ Nearly every day 3. I have recently experienced (Select all that apply)
❑ Restlessness or feeling keyed up or on edge ❑ Irritability ❑ Difficulty falling/staying asleep or restless/unsatisfying sleep ❑ Being easily fatigued ❑ Difficulty concentrating or mind goes blank ❑ None of the above
4. Over the last 2 weeks, how often have you had trouble relaxing? ❑ Not at all
❑ Several days ❑ More than ½ the days ❑ Nearly every day
5. Over the last 2 weeks, how often have you been so restless that it was hard to sit still?
❑ Not at all ❑ Several days ❑ More than ½ the days ❑ Nearly every day
6. Over the last 2 weeks, how often have you been easily annoyed or irritable?
❑ Not at all ❑ Several days ❑ More than ½ the days ❑ Nearly every day
Call (813) 985-5190 to make an appointment to discuss your results. Mention Essential Naples Magazine and receive $150 OFF your initial assessment
(813) 985-5190 1032 Goodlette-Frank Road, Naples
www.savingyourbrain.com
If you would like help for ADHD and/or anxiety bring in this test and receive
$150 OFF
your initial assessment at SAVING YOUR BRAIN.
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