ADHD & Autism Screening Test

Patient Name

Age

Gender
MaleFemaleOther

School/Institute

Address

Any Known Medical Conditions

Your Name

Contact No.

WhatsApp No. (Optional)

Email

Relationship with Patient
ParentGuardianRelativeTeacherOther

Please rate how often the child experiences the following symptoms:

1. Fails to pay close attention to details or makes careless mistakes.
NeverSometimesOftenVery Often

2. Has difficulty sustaining attention in tasks or play activities.
NeverSometimesOftenVery Often

3. Does not seem to listen when spoken to directly.
NeverSometimesOftenVery Often

4. Has difficulty following instructions and fails to finish schoolwork or chores.
NeverSometimesOftenVery Often

5. Has trouble organizing tasks and activities.
NeverSometimesOftenVery Often

6. Avoids or dislikes tasks requiring sustained mental effort.
NeverSometimesOftenVery Often

7. Easily distracted by extraneous stimuli.
NeverSometimesOftenVery Often

8. Often fidgets with hands or feet, or squirms in seat.
NeverSometimesOftenVery Often

9. Leaves seat in situations where remaining seated is expected.
NeverSometimesOftenVery Often

10. Runs about or climbs excessively in inappropriate situations.
NeverSometimesOftenVery Often

1. Avoids eye contact or does not maintain eye contact.
NeverSometimesOftenVery Often

2. Has difficulty understanding others’ feelings or reacting appropriately.
NeverSometimesOftenVery Often

3. Repeats words or phrases out of context (echolalia).
NeverSometimesOftenVery Often

4. Displays repetitive behaviors (e.g., hand flapping, spinning objects).
NeverSometimesOftenVery Often

5. Has extreme reactions to sensory input (e.g., sounds, lights, textures).
NeverSometimesOftenVery Often

6. Prefers playing alone and has difficulty making friends.
NeverSometimesOftenVery Often

7. Sticks to strict routines and has difficulty with changes.
NeverSometimesOftenVery Often

8. Has difficulty with verbal or non-verbal communication.
NeverSometimesOftenVery Often

9. Engages in unusual or intense interests.
NeverSometimesOftenVery Often

10. Has unusual body postures or movements.
NeverSometimesOftenVery Often