The Amen Checklist

Directions:
Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you or the other person (such as a spouse, lover or parent). This is done to obtain a more complete picture of the situation.

0 Never
1 Rarely
2 Occasionally
3 Frequently
4 Very Frequently
NA Not Applicable

Please ensure that you provide your first and last name as well as your e-mail address if you have one. If you do not have an e-mail address or would prefer that we telephone you please type your phone number in the space provided for an E-mail address. It is important that you provide your name so when e-mailing or calling you to reply we know who to speak with. This allows us to provide you with the utmost privacy.

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1. Is easily distracted.
Self Other
2. Has difficulty sustaining attention span for most tasks in play, school or work.
Self Other
3. Has trouble listening when others are talking.
Self Other
4. Has difficulty following through (procrastination) on tasks or instructions.
Self Other
5. Has difficulty keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.).
Self Other
6. Has trouble with time, for example, is frequently late or hurried, tasks take longer than expected, projects or homework are "last minute" or turned in late.
Self Other
7. Has tendency to lose things.
Self Other
8. Makes careless mistakes, poor attention to detail.
Self Other
9. Is forgetful
Self Other
10. Daydreams excessively.
Self Other
11. Complains of being bored.
Self Other
12. Appears apathetic or unmotivated.
Self Other
13. Is tired, sluggish, or slow moving.
Self Other
14. Is spacey or seems preoccupied.
Self Other
15. Is restless or hyperactive.
Self Other
16. Has trouble sitting still.
Self Other
17. Is fidgety, in constant motion (hand, feet, body).
Self Other
18. Is noisy, has a hard time being quiet.
Self Other
19. Acts as if "driven by a motor".
Self Other
20. Talks excessively.
Self Other
21. Is impulsive (doesn't think through comments or actions before they are said or done).
Self Other
22. Has difficulty waiting his or her turn.
Self Other
23. Interrupts or intrudes on others (e.g.. butts into conversations or games).
Self Other
24. Worries excessively or senselessly.
Self Other
25. Is super organized.
Self Other
26. Is oppositional, argumentative.
Self Other
27. Has a strong tendency to get locked into negative thoughts; has the same thought over and over.
Self Other
28. Has a tendency toward compulsive behaviour.
Self Other
29. Has an intense dislike of change.
Self Other
30. Has a tendency to hold grudges.
Self Other
31. Has trouble shifting attention from subject to subject.
Self Other
32. Has difficulties seeing options in situations.
Self Other
33. Has tendency to hold on to own opinions and not listen to others.
Self Other
34. Has a tendency to get locked into a course of actions, whether or not it is good for the person.
Self Other
35. Needs to have things done a certain way or becomes very upset.
Self Other
36. Others complain that he or she worries too much.
Self Other
37. Has periods of quick temper or rages with little provocation.
Self Other
38. Misinterprets comments as negative when they are not.
Self Other
39. Irritability tends to build, then explodes, then recedes; is often tired after a rage.
Self Other
40. Has periods of spaciness or confusion.
Self Other
41. Has periods of panic and/or fear for no specific reason.
Self Other
42. Perceives visual changes, such as seeing shadows or objects changing shape.
Self Other
43. Has frequent bouts of deja vu (feelings of being somewhere before even though he or she has never been there).
Self Other
44. Is sensitive or mildly paranoid.
Self Other
45. Has headache or abdominal pain of uncertain origin.
Self Other
46. Has a history of a head injury or a family history of violence or explosiveness.
Self Other
47. Has dark thoughts, may involve suicidal or homicidal thoughts.
Self Other
48. Has periods of forgetfulness or memory problems.
Self Other
49. Has a short fuse or periods of extreme irritability.
Self Other
50. Is moody.
Self Other
51. Is negative.
Self Other
52. Has low energy.
Self Other
53. Is frequently irritable.
Self Other
54. Has a tendency to be socially isolated.
Self Other
55. Has frequent feelings of hopelessness, helplessness or excessive guilt.
Self Other
56. Has lowered interest in things that are usually considered fun.
Self Other
57. Undergoes sleep changes (too much or too little).
Self Other
58. Has chronic low self-esteem.
Self Other
59. Is angry or aggressive.
Self Other
60. Is sensitive to noise, light, clothes or touch.
Self Other
61. Undergoes frequent or cyclic mood changes (highs and lows)
Self Other
62. Is inflexible, rigid in thinking.
Self Other
63. Demands to have his or her way, even when told no multiple times.
Self Other
64. Has periods of mean, nasty or insensitive behaviour.
Self Other
65. Has period of increased talkativeness
Self Other
66. Has periods of increased impulsivity.
Self Other
67. Displays unpredictable behaviour.
Self Other
68. Way of thinking is grandiose or "larger than life".
Self Other
69. Talks fast.
Self Other
70. Feels that thoughts go fast.
Self Other
71. Appears anxious or fearful.
Self Other