Attachment 1: ADHD Questions to be Tested
Form Approved
OMB No. 0920-0222
Exp. Date: 01/31/2026
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Do you currently have ADHD?
Yes
No
Have you ever talked with a doctor or health professional about whether you have Attention Deficit/Hyperactivity Disorder or ADHD
Yes
No
I wanted to, but was not able to do so
Have you EVER been told by a doctor or health professional that you had…
Attention Deficit/Hyperactivity Disorder or ADHD, sometimes also called Attention Deficit Disorder or ADD?
Yes
No
Have you EVER been told by a teacher or other school staff member that you had… Attention Deficit/Hyperactivity Disorder or ADHD, sometimes also called Attention Deficit Disorder or ADD?
Yes
No
Have you EVER been told by your parent that you had Attention Deficit/Hyperactivity Disorder or ADHD, sometimes also called Attention Deficit Disorder or ADD?
Yes
No
What type of doctor, health care provider, or educator FIRST told you that you had ADHD?
Pediatrician
Family care doctor
Nurse practitioner
Psychologist outside of school
Psychiatrist
School psychologist or counselor
Teacher
Other therapist
Internal medicine
If you ever had ADHD but do not currently have it, what are the reasons?
Condition seemed to go away on its own
Treatment helped the condition to go away.
A doctor or health care provider changed the diagnosis
Other reason:
How old were you when you were first told you had ADD or ADHD?
______
How old were you when you first noticed you had ADD or ADHD symptoms?
______
Would you describe your current ADHD as mild, moderate, or severe?
Mild
Moderate
Severe
When the symptoms were at their worst, how would you describe your ADHD?
Mild
Moderate
Severe
Over the last two weeks, how often have you been bothered by the following problems
... poor attention or hyperactivity/impulsivity?
Not at all
Several days
More than half the days
Nearly every day
Do you currently take prescription medication for ADD or ADHD?
Yes
No
Which of the following treatment has helped you the with your ADHD symptoms?
Medication
Therapy/ Behavior treatment
Coaching
Another type of treatment
None
Have you ever received any telehealth services for ADHD? That is, have you ever talked about your ADHD with a doctor, nurse, or other health professional by video or by phone?
Yes
No
During the past 12 months, have you had an appointment regarding your ADHD with a doctor, nurse, or other health professional by video or by phone?
Yes
No
Were you diagnosed with ADHD during telehealth visits, in-person visits, or a combination of both?
Yes
No
Because of having ADHD, do you have difficulty… Seeking medical treatment for other health conditions?
No difficulty
Some difficulty
A lot of difficulty
Cannot
do at all
Because of having ADHD, do you have difficulty… Keeping medical appointments?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Because of having ADHD, do you have difficulty… Taking medication the way the doctor prescribed?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Because of having ADHD, do you have difficulty… Eating the kinds of foods you should eat for your health?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Because of having ADHD, do you have difficulty… Getting enough exercise for your health?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Because of having ADHD, do you have difficulty… Avoiding injuries?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Because of having ADHD, do you have difficulty… Getting enough sleep?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
The next questions ask about the use of stimulant medications without a doctor's prescription or differently than how a doctor told you to use it. For these questions, count stimulant medications such as Adderall, Vyvanse, Ritalin, Concerta, generic methylphenidate, generic amphetamines or mixed amphetamine salts, or other ADHD medications.
During your life, how many times have you taken stimulant medications without a doctor's prescription or more frequently than how a doctor told you to use it?
0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 or more times
During the past 30 days, how many times have you taken stimulant medications without a doctor's prescription or more frequently than how a doctor told you to use it?
0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 or more times
During your life, how many times have you allowed someone else to use your prescription stimulant medication?
0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 or more times
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Smith, Kelley (CDC/IOD/OPHDST/NCHS) |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |