0920-0222 ADHD Attachment 1 Questions to be tested

Attachment 1: ADHD Questions to be Tested

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026

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1. Do you currently have ADHD?

   1. Yes

   2. No

2. Have you ever talked with a doctor or health professional about whether you have Attention Deficit/Hyperactivity Disorder or ADHD

   1. Yes

   2. No

   3. I wanted to, but was not able to do so

3. 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?

1. Yes

2. No

4. 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?

   1. Yes

   2. No

5. 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?

   1. Yes

   2. No

6. What type of doctor, health care provider, or educator FIRST told you that you had ADHD?

   1. Pediatrician

   2. Family care doctor

   3. Nurse practitioner

   4. Psychologist outside of school

   5. Psychiatrist

   6. School psychologist or counselor

   7. Teacher

   8. Other therapist

   9. Internal medicine

7. If you ever had ADHD but do not currently have it, what are the reasons?

   1. Condition seemed to go away on its own

   2. Treatment helped the condition to go away.

   3. A doctor or health care provider changed the diagnosis

   4. Other reason:

8. How old were you when you were first told you had ADD or ADHD?

______

9. How old were you when you first noticed you had ADD or ADHD symptoms?

______

10. Would you describe your current ADHD as mild, moderate, or severe?

    1. Mild

    2. Moderate

    3. Severe

11. When the symptoms were at their worst, how would you describe your ADHD?

    1. Mild

    2. Moderate

    3. Severe
       
       

12. Over the last two weeks, how often have you been bothered by the following problems

... poor attention or hyperactivity/impulsivity?

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

13. Do you currently take prescription medication for ADD or ADHD?

    1. Yes

    2. No

14. Which of the following treatment has helped you the with your ADHD symptoms?

    1. Medication

    2. Therapy/ Behavior treatment

    3. Coaching

    4. Another type of treatment

    5. None

15. 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?

    1. Yes

    2. No

16. 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?

    1. Yes

    2. No

17. Were you diagnosed with ADHD during telehealth visits, in-person visits, or a combination of both?

    1. Yes

    2. No

18. Because of having ADHD, do you have difficulty… Seeking medical treatment for other health conditions?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all
       
       

19. Because of having ADHD, do you have difficulty… Keeping medical appointments?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all

20. Because of having ADHD, do you have difficulty… Taking medication the way the doctor prescribed?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all

21. Because of having ADHD, do you have difficulty… Eating the kinds of foods you should eat for your health?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all

22. Because of having ADHD, do you have difficulty… Getting enough exercise for your health?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all

23. Because of having ADHD, do you have difficulty… Avoiding injuries?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. Cannot do at all

24. Because of having ADHD, do you have difficulty… Getting enough sleep?

    1. No difficulty

    2. Some difficulty

    3. A lot of difficulty

    4. 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.

25. 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?  

    1. 0 times 

    2. 1 or 2 times  

    3. 3 to 9 times  

    4. 10 to 19 times  

    5. 20 to 39 times  

    6. 40 or more times 

26. 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?  

    1. 0 times  

    2. 1 or 2 times  

    3. 3 to 9 times  

    4. 10 to 19 times  

    5. 20 to 39 times  

    6. 40 or more times 

27. During your life, how many times have you allowed someone else to use your prescription stimulant medication? 

    1. 0 times 

    2. 1 or 2 times  

    3. 3 to 9 times  

    4. 10 to 19 times  

    5. 20 to 39 times  

    6. 40 or more times