ADHD Symptom Questionnaire
Thank you for taking the time to complete this short questionnaire.

You are probably wondering why we are asking you these questions? We love to measure the positive impact of the dietary changes that you are implementing for your child.

We will ask you to complete this questionnaire several times throughout the course, and you will be prompted within the program.

It will not only show you the progression of these dietary changes but also other potential areas of focus.
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Email *
What is your child's name? *
What is your email address? *
Which module are you currently completing? *
Hyperactivity *
Not Noticeable
Severe
Impulsivity / acts without thinking *
Not Noticeable
Severe
Trouble paying attention / staying focused *
Not Noticeable
Severe
Forgetful / loses things *
Not Noticeable
Severe
Anxiety / worry *
Not Noticeable
Severe
Sad / moody *
Not Noticeable
Severe
Irritable / angry *
Not Noticeable
Severe
Rude / cruel / hateful *
Not Noticeable
Severe
Tantrums *
Not Noticeable
Severe
Physical aggression *
Not Noticeable
Severe
Disobedient / defiance *
Not Noticeable
Severe
Sleep problem *
Not Noticeable
Severe
Picky Eating *
Not Noticeable
Severe
Gut Symptoms - Gas, bloating, constipation, diarrhea *
Not Noticeable
Severe
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This form was created inside of Our Road To Thrive.