Copeland Symptom List

Adult Attention Deficit Disorder

This checklist was developed from the experience of many specialists in the field of Attention Disorders and
Hyperactivity. It is designed to help determine whether you, or someone you are rating, has ADHD or ADD and in
which area(s) difficulties are experienced. Please mark all statements. Thank you for your assistance in completing
this information.

Name Date Completed by

Shaded areas for office use only

Please check () every item below, indicating the degree to which the 
Just
behavior is characteristic of yourself or the adult you are rating. Not
a
Pretty Very
Score %
at all much much
little
I. INATTENTION / DISTRACTIBILITY
1. A short attention span, especially for lo-interest activities.
2. Difficulty competing tasks.
3. Daydreaming.
4. Easily distracted.
5. Nicknames such as: "spacey" or "dreamer".
6. Engages in much activity but accomplishes little.
7. Enthusiastic beginnings but poor endings.
/21
II. IMPULSIVITY
1. Excitability.
2. Low frustration tolerance.
3. Acts before thinking.
4. Disorganization.
5. Poor planning ability.
6. Excessively shifts from one activity to another.
7. Difficulty in group situations which require patience and taking turns.
8. Interrupts frequently.
/24
III. ACTIVITY LEVEL PROBLEMS
A. Overactivity / hyperactivity
1. Restlessness - either fidgeting or being constantly on the go.
2. Diminished need for sleep.
3. Excessive talking.
4. Difficulty listening.
5. Restlessness during sleep. Kicks covers off - moves constantly.
6. Dislike of situations which require attention and being still.
B. Underactivity
1. Lethargic
2. Daydreaming, spiciness.
3. Failure to complete tasks.
4. Inattention.
5. Lacking in leadership.
6. Difficulty in getting things done.
/36
IV. NONCOMPLIANCE
1. Does not cooperate. Determined to do things own way.
2. Argumentative.
3. Disregards socially-accepted behavioral expectations.
4. "Forgets" unintentionally.
5. "Forgets" as an excuse (intentionally).
/15
 Copeland Symptom List
Adult Attention Deficit Disorder

V. UNDERACHIEVEMENT / DISORGANIZATION / LEARNING PROBLEMS

1. Underachievement in relation to ability.
2. Frequent job changes.
3. Loses things - keys, wallet, lists, belongings, etc.
4. Auditory memory and auditory processing problems.
5. Learning disabilities or learning problems.
6. Poor handwriting.
7. "Messy" or "sloppy" work.
8. Work assignments are often not completed satisfactorily.
9. Rushes through work.
10. Works too slowly
11. Procrastinates. Bills, taxes, etc., put off until the last minute.
/33
VI. EMOTIONAL DIFFICULTIES
1. Frequent and unpredictable mood swings.
2. Irritability.
3. Underreactive to pain / insensitive to danger.
4. Easily overstimulated. Hard to stop once "revved" up.
5. Low frustration tolerance. Excessive emotional reaction.
6. Angry outbursts.
7. Moodiness / lack of energy.
8. Low self-esteem
9. Immaturity.
/27
VII. POOR PEER RELATIONS
1. Difficulty following the rules of social interactions.
2. Rejected or avoided by peers.
3. Avoids group activity. A loner.
4. "Bosses" other people. Wants to be a leader.
5. Critical of others.
/15
VIII. IMPAIRED FAMILY RELATIONS
1. Easily frustrated with spouse or children. Overreacts. May punish children too severely.
2. Sees things from own point of view. Does not negotiate differences well.
3. Underdeveloped sense of responsibility.
4. Poor manager of money.
5. Unreasonable; demanding.
6. Spends excessive amount of time at work because of inefficiency, leaving little time for family.
/18

SCORING FOR THE COPELAND SYMPTOM CHECKLIST (ADHD / ADD)

(Child / Adolescent Checklist and Adult Checklist)

1. Scores: Not at all = 0 Just a little = 1 Pretty much = 2 Very much = 3

2. Each check receives a score from 0-3. Add the checks in each category. That score is placed over the total
possible.
3. Compute the percentages for each category: Scores between 35-49% suggest mild to moderate difficulties.
Scores between 50-69% suggest moderate to severe difficulties. Scores above 70% suggest major
interference.

Note: Children, adolescents and adults may have difficulties in only one area or all ten. Those with undifferentiated ADD on the
more daydreaming, inattentive, anxious end of continuum frequently manifest difficulties only in the “Inattention/Distractibility”,
“Underactivity”, and the “UNDERACHIEVEMENT” categories, while those with overactive, impulsive ADHD will have difficulties in
many more areas of their lives.
Wender Utah Rating Scale for the Attention Deficit Hyperactivity
Disorder

Overview:

The Wender Utah Rating Scale can be used to assess adults for Attention Deficit
Hyperactivity Disorder with a subset of 25 questions associated with that
diagnosis.

Wender Utah Rating Scale

 61 questions answered by the adult patient recalling his or her childhood

behavior
 5 possible responses scored from 0 to 4 points

As a child I was (or had): not at all mildly moder- quite very
or very ately a bit much
slightly
1 active restless always on the 0 1 2 3 4
go
2 afraid of things 0 1 2 3 4
3 concentration problems 0 1 2 3 4
easily distracted
4 anxious worrying 0 1 2 3 4
5 nervous fidgety 0 1 2 3 4
6 inattentive daydreaming 0 1 2 3 4
7 hot- or short-tempered low 0 1 2 3 4
boiling point
8 shy sensitive 0 1 2 3 4
9 temper outbursts tantrums 0 1 2 3 4
10 trouble with stick-to-it- 0 1 2 3 4
tiveness not following
through. failing to finish
things started
11 stubborn strong-willed 0 1 2 3 4
12 sad or blue depressed 0 1 2 3 4
unhappy
13 incautious. dare-devilish 0 1 2 3 4
involved in pranks
14 not getting a kick out of 0 1 2 3 4
things dissatisfied with life
15 disobedient with parents 0 1 2 3 4
rebellious sassy
16 low opinion of myself 0 1 2 3 4
17 irritable 0 1 2 3 4
 not at all mildly moder- quite very
or very ately a bit much
slightly
18 outgoing friendly enjoyed 0 1 2 3 4
company of people
19 sloppy disorganized 0 1 2 3 4
20 moody ups and downs 0 1 2 3 4
21 angry 0 1 2 3 4
22 friends popular 0 1 2 3 4
23 well-organized tidy neat 0 1 2 3 4
24 acting without thinking 0 1 2 3 4
impulsive
25 tendency to be immature 0 1 2 3 4
26 guilty feelings regretful 0 1 2 3 4
27 losing control of myself 0 1 2 3 4
28 tendency to be or act 0 1 2 3 4
irrational
29 unpopular with other 0 1 2 3 4
children didn't keep friends
for long didn't get along with
other children
30 poorly coordinated did not 0 1 2 3 4
participate in sports
31 afraid of losing control of self 0 1 2 3 4
32 well-coordinated picked first 0 1 2 3 4
in games
33 tomboyish (for women only) 0 1 2 3 4
34 running away from home 0 1 2 3 4
35 getting into fights 0 1 2 3 4
36 teasing other children 0 1 2 3 4
37 leader bossy 0 1 2 3 4
38 difficulty getting awake 0 1 2 3 4
39 follower led around too 0 1 2 3 4
much
40 trouble seeing things from 0 1 2 3 4
someone else's point of view
41 trouble with authorities 0 1 2 3 4
trouble with school visits to
principal's office
42 trouble with police booked 0 1 2 3 4
convicted
 Medical problems as a not at all mildly moder- quite very
child or very ately a bit much
slightly
43 headaches 0 1 2 3 4
44 stomachaches 0 1 2 3 4
45 constipation 0 1 2 3 4
46 diarrhea 0 1 2 3 4
47 food allergies 0 1 2 3 4
48 other allergies 0 1 2 3 4
49 bedwetting 0 1 2 3 4
As a child in school I was not at all mildly moder- quite very
(or had) or very ately a bit much
slightly
50 overall a good student fast 0 1 2 3 4
51 overall a poor student slow 0 1 2 3 4
learner
52 slow in learning to read 0 1 2 3 4
53 slow reader 0 1 2 3 4
54 trouble reversing letters 0 1 2 3 4
55 problems with spelling 0 1 2 3 4
56 trouble with mathematics or 0 1 2 3 4
numbers
57 bad handwriting 0 1 2 3 4
58 able to read pretty well but 0 1 2 3 4
never really enjoyed reading
59 not achieving up to potential 0 1 2 3 4
60 repeating grades 0 1 2 3 4
61 suspended or expelled 0 1 2 3 4
 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Patient Name Today’s Date
Please answer the questions below, rating yourself on each of the criteria shown using the

Very Often
Sometimes
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

Rarely
Never

Often
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?
2. How often do you have difficulty getting things in order when you have to do
a task that requires organization?
3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid
or delay getting started?

5. How often do you fidget or squirm with your hands or feet when you have
to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you
were driven by a motor?
Part A
7. How often do you make careless mistakes when you have to work on a boring or
difficult project?

8. How often do you have difficulty keeping your attention when you are doing boring
or repetitive work?
9. How often do you have difficulty concentrating on what people say to you,
even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?

11. How often are you distracted by activity or noise around you?

12. How often do you leave your seat in meetings or other situations in which
you are expected to remain seated?

13. How often do you feel restless or fidgety?

14. How often do you have difficulty unwinding and relaxing when you have time
to yourself?

15. How often do you find yourself talking too much when you are in social situations?

16. When you’re in a conversation, how often do you find yourself finishing
the sentences of the people you are talking to, before they can finish
them themselves?
17. How often do you have difficulty waiting your turn in situations when
turn taking is required?

18. How often do you interrupt others when they are busy?

Part B