ATTENTION SKILLS QUESTIONNAIRE

Identification Section
Name: ___________________________
Age: _______
Gender: ☐ Male ☐ Female ☐ Other
Date: ___________________________
Completed by: ☐ Parent ☐ Teacher ☐ Clinician ☐ Self

SECTION 1: ATTENTION SPAN AND FOCUS

1. How long can the person stay focused on a task or activity they enjoy (e.g., drawing, gaming, building)?
   ☐ Less than 2 minutes
   ☐ 2–5 minutes
   ☐ 5–10 minutes
   ☐ More than 10 minutes
2. How long can the person stay focused on less preferred tasks (e.g., schoolwork, chores)?
   ☐ Less than 1 minute
   ☐ 1–3 minutes
   ☐ 3–10 minutes
   ☐ More than 10 minutes
3. Does the person often get distracted by noises, people, or objects around them?
   ☐ Rarely
   ☐ Sometimes
   ☐ Often
   ☐ Very often
4. Does the person need frequent reminders to return to a task?
   ☐ Never
   ☐ Occasionally
   ☐ Frequently
   ☐ Constantly
5. When reading or listening, does the person lose track of what is being said or read?
   ☐ Never
   ☐ Occasionally
   ☐ Frequently
   ☐ Always

SECTION 2: ATTENTIONAL CONTROL AND SHIFTING

6. Can the person switch focus easily between two different tasks (e.g., listening to instructions and writing)?
   ☐ Easily
   ☐ With some difficulty
   ☐ Only with prompting
   ☐ Unable to switch without help
7. Does the person become “stuck” on a particular thought or activity and struggle to move on?
   ☐ Never
   ☐ Occasionally
   ☐ Frequently
   ☐ Always
8. Does the person ignore important details because their attention is captured by something else?
   ☐ Rarely
   ☐ Sometimes
   ☐ Often
   ☐ Very often
9. How well does the person recover attention after being interrupted?
   ☐ Instantly
   ☐ With a brief pause
   ☐ With reminders
   ☐ With great difficulty

SECTION 3: SUSTAINED ATTENTION AND MENTAL EFFORT

10. Does the person tire easily when doing mental tasks (e.g., reading, problem-solving)?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
11. Does the person rush through tasks or give up before completion?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
12. When working for longer periods, does performance decline (more mistakes, restlessness)?
    ☐ No decline
    ☐ Slight decline
    ☐ Moderate decline
    ☐ Marked decline

SECTION 4: ORGANIZATION AND ATTENTIVE BEHAVIOUR

13. Does the person often forget instructions, even if they were recently given?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
14. Does the person lose or misplace belongings (books, keys, stationery, etc.)?
    ☐ Rarely
    ☐ Sometimes
    ☐ Often
    ☐ Very often
15. Does the person start tasks without understanding what to do first?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
16. Does the person appear daydreamy, “in their own world,” or inattentive during lessons or conversations?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always

SECTION 5: BEHAVIOURAL SIGNS OF INATTENTION

17. Does the person appear fidgety, restless, or constantly move while seated?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
18. Does the person interrupt others or speak before a question is completed?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
19. Does the person blurt out answers or act without thinking through consequences?
    ☐ Never
    ☐ Occasionally
    ☐ Frequently
    ☐ Always
20. Does the person seem easily bored or constantly seek new stimulation?
    ☐ Rarely
    ☐ Sometimes
    ☐ Often
    ☐ Very often

SECTION 6: FUNCTIONAL IMPACT

21. Do attention problems interfere with school or work performance?
    ☐ Not at all
    ☐ Slightly
    ☐ Moderately
    ☐ Severely
22. Do attention problems affect social interactions (e.g., not listening to peers, missing cues)?
    ☐ Not at all
    ☐ Slightly
    ☐ Moderately
    ☐ Severely
23. Do attention issues cause frustration, low confidence, or emotional distress?
    ☐ No
    ☐ Occasionally
    ☐ Frequently
    ☐ Always

SCORING / CLINICAL INTERPRETATION (for clinician use)

• 0 = Rarely/Never
• 1 = Occasionally/Sometimes
• 2 = Frequently/Often
• 3 = Always/Very often

Higher total scores suggest greater attention difficulties. Sectional patterns can guide whether difficulties are in sustained attention, shifting, or executive control.