Adult Screen of Executive Functioning
© William D. Kennedy, Psy.D.  
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Client Name
Age
Date of Birth
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Date of Birth
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Please read the following questions and answer them.  If you are filling this out about yourself, choose the answer that best fits for you.  If you are filling this out about someone else, then list how you see them doing the following items.
Never
Sometimes
Often
Very Often
I am easily distracted by situations or things going on around me.
I make decisions impulsively.
I have trouble stopping behaviors or activities when I should.
I start projects or tasks without reading or listening to the directions carefully.
I have poor follow-through on promises or commitments I make to others.
I have trouble doing things in their proper order or sequence.
I drive a motor vehicle much faster than others (excessive speeding)
I have trouble sustaining my attention on tasks or activities.
I have difficulty organizing tasks and activities.
Clear selection
If you are filling this out about yourself, rate the amount of difficulty and problems you face in each of the following areas.   If you are filling this out about someone else, then rate the amount of difficulty and problems that you see him or her experiencing in the following areas.
None
Mild
Moderate
Severe
Home life such as cleaning, schedules, and routines
Work or Occupation
Social Interactions
Community Activities
Education Activities
Dating or Marital Activities
Money Management, Spending, Budgeting
Driving
Leisure Activities
Daily Responsibilities
Clear selection
Submit
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