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Executive Function Questionnaire

The document describes an executive function questionnaire to help clinicians assess patients for executive function disorders like ADD. It includes questions in different categories related to initiation, completion, execution, distraction, perseverance, inattentiveness, memory, time management, future planning, organization, physical activity, frustration, impulsiveness, anxiety, multitasking, and sleep. Scoring is from 0 to 3 based on how well statements describe the individual. The goal is to identify issues for clinical evaluation, as simply adding scores is not enough to diagnose ADD on its own.

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ANDREA PAOLA GALVEZ DEL CID
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297 views3 pages

Executive Function Questionnaire

The document describes an executive function questionnaire to help clinicians assess patients for executive function disorders like ADD. It includes questions in different categories related to initiation, completion, execution, distraction, perseverance, inattentiveness, memory, time management, future planning, organization, physical activity, frustration, impulsiveness, anxiety, multitasking, and sleep. Scoring is from 0 to 3 based on how well statements describe the individual. The goal is to identify issues for clinical evaluation, as simply adding scores is not enough to diagnose ADD on its own.

Uploaded by

ANDREA PAOLA GALVEZ DEL CID
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Executive Function Questionnaire

Executive functions include planning, managing time, remembering, and reasonably controlling
emotional states. The clinician's assessment of an individual's answers to the questions below
(and also of the individual's family's answers, if possible) can help determine whether a patient
is experiencing a deficit in executive functions.

A common cause of Executive Function Disorder is ADD, but there are other causes as well,
such as depression, Alzheimer's, schizophrenia, and anxiety. For this reason, simply adding up
an individual's score on all the questions is not useful for making the diagnosis of ADD. The
main value of the questionnaire is to identify issues that are important to assess when carrying
out an evaluation. Clinical judgment and experience are required to interpret the answers and
make the proper diagnosis.

Scoring Key
Answer how well each statement describes you when you don't use special aids or tricks you
have developed to get around or compensate for difficulties you might have. Score each answer
as follows:
0 - doesn't describe me at all
1 - describes me somewhat
2 - describes me pretty well
3 - describes me very well
Score
INITIATION
I have trouble getting started doing things
I procrastinate

COMPLETION
I have trouble completing things

EXECUTION
I don't do tasks efficiently (good job in short time)
It is hard for me to do two or three tasks in a row.
I don't always do what needs to be done.

DISTRACTION
I am easily distracted by things I hear or see even when I am trying to concentrate

PERSEVERANCE AND FOCUS


I don't stick to tasks that are optional
I can't stick to a task even if I have to
I often switch from doing one thing to another

INATTENTIVENESS
I don't pay attention when I should
I day dream/space out
I have trouble listening while others speak to me
I am absent minded
Score
MEMORY
I have trouble remembering things I want to do
I get so deeply into one thing that I forget others
I have trouble with my short term memory
I lose or misplace things

TIME
I confuse appointment times
I forget appointments
I am often late for appointments

FUTURE AWARENESS AND PLANNING


I have trouble making plans long in advance
I let my gas tank needle get close to empty
I rarely get to trains at least 10 minutes early

ORGANIZATION
I get disorganized
My personal work area is messy
I put on my seat belt after the car has started moving
I don't prioritize or plan my day
I can't work well without structure or direction
I have difficulty taking command of my time.
I waste a lot of time doing nothing.

PHYSICAL ACTIVITY (HYPERACTIVITY)


I need to keep walking, moving around
I have trouble sitting still, I fidget

FRUSTRATION/IMPULSIVENESS
I get angry easily
I am easily frustrated
I get impatient easily
I interrupt when other people are talking
I am impulsive, do things without thinking
I don't express or communicate my anger constructively

ANXIETY
I focus and concentrate better if I am somewhat anxious.

MULTI-TASKING (parallel)
I have trouble doing more than one thing at a time well
I often try to do more than one task at a time
I tend to make things more complicated than they need to be
Score
MULTI-TASKING (serial)
I dislike tasks that require a long series of steps

SLEEP
I have trouble getting to sleep because my mind is going

UNCATEGORIZED
I get so deeply into one thing that I forget other things I have to do
I believe that there is usually a quick solutions to problems
I do not like to commit because I don't know how I will feel in the long term

Impressions/Comments:

Copyright Marc Schwartz, MD, 2000-2007, New Haven, CT. All rights reserved. Version 2.34
(http://adultadd.info/Questionnaire.htm)

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