Do you experience any of the following?

Trouble paying attention to details? Yes No

Trouble sustaining attention when engaged in activities that are unexciting, but are important, necessary, or expected of you? Yes No

Difficulty listening when directly addressed (Space off)? Yes No

Difficulty following instructions or finishing tasks (Initiating several tasks, but not finishing any or most of them within a reasonable time)? Yes No

Trouble with organizational skills (Frequently misplacing keys or loosing paperwork)? Yes No

Forgetfulness (Missing appointments)? Yes No

Becoming easily distracted, or make careless mistakes because you're not focusing? Yes No

Frequently fidgeting or squirming (Pacing or playing with pens, clothing articles, or hair)? Yes No

Always "on the go"? Yes No

Talking excessively? Yes No

Acting without thinking? Yes No

Interrupting or intruding on others? Yes No

First Name: *

Last Name: *

Telephone: *

Best time to call:

E-mail address: *

City Name: *

IMPORTANT
Choose the location nearest you: * Choose a location Salem, OR Portland, OR