Name: Sincere Psychiatry
Address: 16244 S Military Trail, Unit 130, Delray, FL33484
Telephone: +1-(561) 455-2603
Price range: $$

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Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
Never Rarely Sometimes Often Very Often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
Never Rarely Sometimes Often Very Often
3. How often do you have problems remembering appointments or obligations?
Never Rarely Sometimes Often Very Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Never Rarely Sometimes Often Very Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
Never Rarely Sometimes Often Very Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
Never Rarely Sometimes Often Very Often

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