Name
First Name
Last Name
1. I could be experiencing some emotion and not be conscious of it until some time later.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
2. I break or spill things because of carelessness, not paying attention, or thinking of something else.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
3. I find it difficult to stay focused on what's happening in the present.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
4. I tend to walk quickly to get where I'm going without paying attention to what I experience along the way.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
5. I tend not to notice feelings of physical tension or discomfort until they really grab my attention.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
6. I forget a person's name almost as soon as I've been told it for the first time.
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
7. It seems I am "running on automatic," without much awareness of what I'm doing.
*
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
8. I rush through activities without being really attentive to them.
*
1 - Almost Always
2 - Very Frequently
3 - Somewhat Frequently
4 - Somewhat Infrequently
5 - Very Infrequently
6 - Almost Never
