Please return this letter with the completed questionnaires. Thank you!

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Lorraine Blake
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1 Administration & Patient Financial Services 3300 S. Parker Rd., #404 Aurora, Colorado Clinical Offices 5657 S. Himalaya St., #100 Centennial, Colorado S. Potomac St., #156 Aurora, Colorado Date: Child s Name: Date of Birth: Phone Number: 9397 Crown Crest Blvd., #330 Parker, Colorado Central Park Blvd., #202 Denver, CO Freeman Ginsburg, MD, FAAP Stephanie S. Stevens, MD, FAAP Bradley D. Kurtz, DO, FAAP William S. C. Payne, MD, FAAP Alison Auster, MD, FAAP Bethany M. Carvajal, MD, FAAP Danielle M. Clancy, MD, FAAP Jill Kramer, MD, FAAP Elizabeth L. Kudron, MD, FAAP Alyssa Le, MD, FAAP Dear Parent: Enclosed is the ADHD packet you requested for your child. Included in the packet are questionnaires for you, as well as for your child s teacher(s) to complete. If your child is of middle school age or older, it is necessary to have completed questionnaires from at least two teachers to facilitate proper diagnosis of your child. In order to adequately score and evaluate the information we will need the questionnaires and any school evaluations returned before an appointment is made. We will also request that you schedule the initial ADHD evaluation and all follow-up visits with the care provider that your child sees most often for well-care exams. Please be aware, there are additional charges involved in the scoring and evaluation of these questionnaires. These charges will be added to the office visit charge on the date of the visit. Thank you for your cooperation in completing and returning the packet to our office. Once we have received the questionnaires we will contact you to make the appointment for the ADHD evaluation. In the meantime, please do not hesitate to call, (720) , if you have any further questions. Nancy J. McDermott, MD, FAAP Jeanne Oh, MD, FAAP Suzanne L. Rogers, DO, FAAP Katie Truettner, DO, FAAP Enclosures Sincerely, ADD Specialist Nancy Barber Starr, MS, CPNP-PC Brigette Denning, MS, PA-C Please return this letter with the completed questionnaires. Thank you! Joy Diamond, MS, CPNP-PC JaNae Haycock, MS, CPNP-PC Heather Meister, MPAS, PA-C Lynda Melton, MS, PA-C Ryan Pahlau, MPAS, PA-C For internal use only: Appointment: Packet reviewed by: Time spent in Review: Time Required for Appt: ADD064-Rev0317 Jacob H. Perry, MPAS, PA-C Kara Scholl, PA-C Phone Fax

2 Advanced Pediatric Associates ADHD Initial Parent Questionnaire Today s Date: How were you referred to APA: Child s Name: DOB: School: Grade: School Phone: Previous schools attended: Mother s name: Marital status: Occupation: Highest grade finished: Father s name: Marital status: Occupation: Highest grade finished: Other children in family: Name Age Medical/School Problems In your own words what is the reason for this consultation: When was the problem first noticed or previous treatment: Has your child been receiving special classes or resources in school? If so describe? Has an Individual Education Plan been completed for your child? If more space is needed to answer questions, please attach a separate page. ADD066 Rev0410

3 ADHD Initial Parent Questionnaire- Page 2 Family History Please check any of the following conditions that any close blood relative of your child currently has or has had in the past. Please note the relationship of that person to the child. (If child is adopted, check here ) Conditions Birth defects/malformations or death before 1 year of age Sudden death in children or young adults Cardiac (heart) history of hypertrophic cardiomyopathy or long QT syndrome Headaches/migraines Seizures Blindness/Deafness or hearing loss Bedwetting Learning problems/school problems Hyperactivity or ADD Tics/involuntary movements Mental Retardation Emotional or Psychiatric Problems such as depression/anxiety/bipolar Alcoholism or drug addiction/dependency Imprisonment/problems with law Relative/Relationship Pregnancy History (to be completed by the child s mother) During your pregnancy with this child: 1. Did you experience any problems or complications? If so, explain: 2. Did you use (check if yes) Cigarettes Alcohol Nonprescription medications Prescription medications Street drugs(marijuana included) How many per day? How much? Which ones? Which ones? Which ones? 3. Were you exposed to any toxic substance? If so explain: 4. Labor and Delivery Information: Please check any of the following that apply to your labor and delivery of this child: Premature by weeks Late by weeks Labor was induced Medications during labor General anesthesia Baby needed oxygen C-Section(elective or emergency?) Forceps delivery Breech position Fetal distress Meconium (baby s stool) in amniotic fluid Baby required resuscitation Other problems: Birth weight: Length: Apgar Scores (if known): ADD066 Rev0410

4 ADHD Initial Parent Questionnaire-Page 3 Nursery Stay and First Weeks Please check any of the following that apply to the child s first two weeks Respiratory Distress Jaundice Infection Photo-therapy (blue light treatment) Feeding problems Sleep Problems Illness: Surgery: How long did the baby stay in the hospital nursery? Infancy Please check any of the following that apply to your child s first year: Feeding problems Sleep problems Cried a lot Colic Poor weight gain Problems getting on predictable schedule Was never cuddly Breast fed until months Bottle fed until months Was a source of worry or concern Childhood Development Please indicate, as best as you remember, the age in months at which your child did the following: Rolled over Spoke first word Sat without support Able to say 4-6 words Crawled Spoke2-3 word sentences Walked along furniture Could name 4 body parts Walked without support Toilet trained for daytime Used spoon to feed self Dry at night Dressed without help Could name 4 colors Could ride tricycle Developed handedness (Rt/Lft) Please check any of the following that apply to your child during the first few years of life: Much more active than other children Problems sharing Learned to do things very quickly Didn t care how others felt Dare-Devil Behavior (had no fear) Not affected by discipline Impulsive behavior Unable to learn or follow rules Destroyed toys more than other children Wanted to be left alone Aggressive towards other children Needed constant attention Timid or shy Always testing limits Needed a rigid daily schedule Many tantrums Problems adapting to new situations Rocking or head banging Gave up easily when frustrated Problems with sleeping Wandered away from home frequently Problems with eating More interested in things than people Problems with speech Needed to touch and smell everything Clumsiness/Accident prone Problems separating from parents Unable to wait his/her turn ADD066 Rev0410

5 ADHD Initial Parent Questionnaire-Page 4 Medical History Please give approximate dates and a brief explanation for any of the following: Hospitalizations: Previously detected heart disease or conditions, palpitations, syncope (fainting), or seizures: Surgeries: Concussion, skull fracture or serious head injury: Poison ingestion or overdose: Serious illness: Serious accident: History of molestation: Allergies to medicine: Counseling received? Allergies to foods: Other allergies: Medicines taken regularly (include dosage): Please check any of the following that your child has or has had: Seizures Urinary infections Vision problems Bedwetting Ear infections Soiling Hearing problems Hay fever/asthma/eczema Hepatitis/liver disease Anemia Serious vomiting/diarrhea Headaches Constipation Abdominal pain Problems gaining weight Problems growing Tics/involuntary movements Accident prone Kidney disease ADD066 Rev0410

6 Home Situations Questionnaire Evaluating Family Problems Sometime during the next week take a moment to sit down and complete this part of the questionnaire. You have been shown that many problems occurring in your own life can influence how you react to your child s behavior. We think it is important that you evaluate your family life to see whether such problems exist, and if so, what you are doing about them. In the space provided below each problem area, write down the types of problems you may be having in this area. Then write down what it is you are trying to do about the problem to solve it. Don t be afraid to say that you are not doing anything at this time to solve a problem. We simply want to know what types of problems you are having now. Please be as honest as you can as this information is very important to our helping you with your child. Problem Area Health Problems Proposed Solutions Marital Problems Occupation/Work Problems Problems with Relatives/ In Laws Problems with Friends Problems with Other Children in the Family Personal or Emotional Problems Financial Problems Other Problems (religion, sex, drugs, alcohol, abuse, etc) Thank you for taking the time to complete this part of the questionnaire. It will be kept strictly confidential and not released to anyone without your permission. ADD066 Rev0410

7 Social Skills Assessment-Parent s Form Please check in the most appropriate box the degree to which the following statements accurately describe your child. Seems to be a social isolate, e.g., Spends a large proportion of time in solitary activities and may be judged independent and capable of taking care of him/herself. Seems to interact less with classmates and appears shy and timid. May be described as somewhat anxious with others. Seems to spend less time involved in activities with others due to a lack of social skills and/or appropriate social judgement. Seems to have fewer friends that most due to negative, bossy or annoying behaviors which turn off others. Seems to spend less time with classmates than most due to awkward or bizarre behaviors Disturbs other children: teases, provokes, fights, interrupts others. Openly strikes back with angry behavior to teasing of other children. Argues and must have the last word in verbal exchange Displays physical aggression towards objects or persons. Use coercive tactics to force the submission of peers; manipulates or threatens Speaks to others in an impatient or cranky tone of voice Says uncomplimentary or unpleasant things to other children, e.g., engages in name calling, ridicule, verbal degradation Mild Moderate Severe ADD066 Rev0410

8 Today's Date: CARING FOR CHILDRENS WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION NICHQ Vanderbilt Assessment Scale: Parent Informant Child's Name: Child's Date of Birth: Parent's Name: Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When conpleting this form, please think about your child's behaviors in the past 6 months. Is this evaluation based on a time when the child was on medication was not on medication not sure? Symptoms Never (0) 1 Does not pay attention to details or makes careless mistakes with, for example, homework 2 Has difficulty keeping attention to what needs to be done 3 Does not seem to listen when spoken to directly 4 Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) 5 Has difficulty organizing tasks and activities 6 Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 7 Loses things necessary for tasks or activities (toys, assignments, pencils, books) 8 Is easily distracted by noises or other stimuli Is forgetful in daily activities Occasionally (1) Often (2) Very Often (3) & 3s: / Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs about or climbs too much when remaining seated is expected Has difficulty playing or beginning quiet play activities Is "on the go" or often acts as if "driven by a motor" Talks too much Blurts out answers before questions have been completed Has difficulty waiting his or her turn Interrupts or intrudes in on others' conversations and/or activities Argues with adults Loses temper actively defies or refuses to go along with adults' requests or rules Deliberately annoys people Blames others for his or her mistakes or misbehaviors Is touchy or easily annoyed by others Is angry or resentful Is spiteful and wants to get even 2 & 3s: / & 3s: /8 ASSESSMENT AND DIAGNOSIS ADD067 - Rev1114

9 Symptoms (cont.) CARING FOR CHILDRENS WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION Never (0) Occasionally (1) Often (2) Very Often (3) & 3s: / Bullies, thereatens, or intimidates others Starts physical fights Lies to get out of trouble or to avoid obligations (ie. "cons" others) Is truant from school (skips school) without permission Is physically cruel to people Has stolen things that have value Deliberately destroys others' property Has used a weapon that can cause serious harm (bat, knife, brick, gun) Is physically cruel to animals Has deliberately set fires to cause damage Has broken into someone's home, business, or car Has stayed out at night without permission Has run away from home overnight Has forced someone into sexual activity Is fearful, anxious, or worried Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved; complains "no one loves him/her" Is sad, unhappy, or depressed Is self-concious or easily embarrassed Excellent (1) Above Average (2) Average (3) 3 If YES to 1 or 2, do these tics interfere with the child's activities (like reading, writing, walking, talking, or eating)? Previous Diagnosis and Treatment: To the best of your knowledge, please answer the following questions: 1 Has your child been diagnosed with a tic disorder or Tourette syndrome? 2 Is your child on medicitation for a tic disorder or Tourette syndrome? 3 Has your child been diagnosed with depression? 4 Is your child on medication for depression? 5 Has your child been diagnosed with any anxiety disorder? 6 Has your child been diagnosed with a learning or language disorder? Somewhat of a Problem (4) Problematic (5) 2 & 3s: /7 Performance 48 Reading 49 Writing 4s: /3 50 Mathmatics 5s: /3 51 Relationship with parents 52 Relationship with siblings 53 Relationship with peers 4s: /4 54 Participation in organized activities (eg. teams) 5s: /4 Other Conditions Tic Behaviors: To the best of your knowledge, please indicate if this child displays the following behaviors: 1 Motor Tics: Rapid, repetitive movements such as eye blinking, grimacing, nose twitching, head jerks, shoulder shrugs, arm jerks, body jerks, or rapid kicks. No tics present Yes, they occur nearly every day but go unnoticed by most Yes, noticeable tics occur nearly every day Phonic (Vocal) Tics: Repetitive noises including but not limited to throat clearing, coughing, whistling, sniffing, snorting, screeching, barking grunting, or repetition of words or short phrases. No tics present Yes, they occur nearly every day but go unnoticed by most Yes, noticeable tics occur nearly every day No No No No No No Yes Yes Yes Yes Yes Yes No Yes ASSESSMENT AND DIAGNOSIS ADD067 - Rev1114

10 Date: Child s Name: Date of Birth: Dear Teacher: The parent(s) of the above child have requested an evaluation by our office for a health concern. As part of the evaluation process, we ask that both the child s parent(s) and teacher(s) complete a set of behavioral rating scales. Enclosed please find a set of teacher rating scales and questionnaires for your attention. These forms include: (1) Teacher Questionnaire; (2) NICHQ Vanderbilt Teacher Assessment Scale; (3) Social Skills Assessment Teacher s Form; and (4) School Data Form. Generally, the teacher who spends the most time with the child should complete these forms. However, if the child has more than one primary teacher, or has a special education teacher, it would be useful for us to obtain a separate set of forms from each teacher. If this is the case, please feel welcome to make the necessary copies. Please fill out the forms as completely as possible. If you do not know the answer to a question, please write Don t know, so that we can be sure the item was not overlooked. After the forms are completed, please return them to the child s parent(s) for forwarding to our office. Thank you for your assistance and cooperation in the completion of these forms. If you have any questions please do not hesitate to contact our office. Sincerely, Enclosure ADD Coordinator ADD068 Rev0215

11 Advanced Pediatric Associates Teacher s Questionnaire Child s Name_ Date Completed School Name_ Child s Grade Teacher s Name Subject Taught Hours with child (daily average) Number of students in class 1. How long have you known this child? In your own words briefly describe this child s main problem: 2. List subjects into the appropriate category: Very Good Average Barely Passing Failing 3. Please list or describe any special help or services this child is receiving in your class: Outside your class: 4. Please rate this child s behavior compared to other children the same age: Much Worse Worse About the Same Better Much Better ADD069 Rev0410

12 Social Skills Assessment-Teacher s Form Student s Name Date Teacher s Name Please check in the most appropriate box the degree to which the following statements accurately describe your child. Seems to be a social isolate, e.g., spends a large proportion of time in solitary activities and may be judged independent and capable of taking care of him/herself. Seems to interact less with classmates and appears shy and timid. May be described as somewhat anxious with others. Seems to spend less time involved in activities with others due to a lack of social skills and/or appropriate social judgement. Seems to have fewer friends than most due to negative, bossy or annoying behaviors which turn off others. Seems to spend less time with classmates than most due to awkward or bizarre behaviors Disturbs other children: teases, provokes, fights, interrupts others. Openly strikes back with angry behavior to teasing of other children. Argues and must have the last word in verbal exchange Displays physical aggression towards objects or persons. Uses coercive tactics to force the submission of peers; manipulates or threatens Speaks to others in an impatient or cranky tone of voice Says uncomplimentary or unpleasant things to other children, e.g., engages in name calling, ridicule, verbal degradation Mild Moderate Severe ADD069 Rev0410

13 School Data (to be completed by the school records office) Student Current School Placement and Grade A. Record the Results of any IQ or other educational test this student has taken: B. School Attendance: Total Days Absent this year Total Days Absent last school year Were any of these absences due to truancies? { } Yes { } No If yes how many? C. Please record the grades from the most recent report card: How do they compare to last year? { } Poorer { } Same { } Better D. Results of most recent visual acuity test (if available): E. Results of most recent audiometrics (if available): F. Please list consultations previously obtained from psychologists, neurologists, speech therapists, etc., or school staff: ADD069 Rev0410

14 CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION NICHQ Vanderbilt Assessment Scale: Teacher Informant Today's Date: Child's Name: Date of Birth: Teacher's Name: Class Name: Period: Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors:. Symptoms Fails to give attention to details or makes careless mistakes in schoolwork. Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish schoolwork (not due to opositional behavior or failure to understand) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils, books) Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Never Occasionally Often Very Often 2 & 3s: /9 12 Runs about or climbs excessively in situations in which remaining seated is expected Has difficulty playing or engaging in leisure activities quietly Is "on the go" or often acts as if "driven by a motor" Talks excessively Blurts out answers before questions have been completed Has difficulty waiting in line 18 Interrupts or intrudes in on others' conversations and/or activities (eg, butts into conversations/games) 19 Loses temper 20 Actively defies or refuses to go along with adults' requests or rules 21 Is angry or resentful 22 Is spiteful and vindictive 23 Bullies, threatens, or intimidates others 24 Initiates physical fights 25 Lies to obtain goods for favors or to avoid obligations (ie. "cons" others) 26 Is physically cruel to people 27 Has stolen items of nontrivial value 28 Deliberately destroys others' property 2 & 3s: /9 2 & 3s: ASSESSMENT AND DIAGNOSIS ADD070 - Rev0115

15 CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION Symptoms 29 Is fearful, anxious, or worried Never Occasionally Often Very Often 30 Is self-concious or easily embarrassed 31 Is afraid to try new things for fear of making mistakes 32 Feels worthless or inferior 33 Blames self for problems; feels guilty 34 Feels lonely, unwanted, or unloved; complains "no one loves him/her" 35 Is sad, unhappy, or depressed Academic Performance 36 Reading Excellent Above Average Average Somewhat of a Problem Problematic 2 & 3s: /7 37 Mathmatics 4s: /3 38 Written expression 5s: /3 Classroom Behavioral Performance 39 Relationship with peers 40 Following directions 41 Disrupting class 42 Assignment completion 4s: /5 43 Organizational skills 5s: /5 Other Conditions Tic Behaviors: To the best of your knowledge, please indicate if this child displays the following behaviors: 1 Motor Tics: Rapid, repetitive movements such as eye blinking, grimacing, nose twitching, head jerks, shoulder shrugs, arm jerks, body jerks, or rapid kicks. 2 Phonic (Vocal) Tics: Repetitive noises including but not limited to throat clearing, coughing, whistling, sniffing, snorting, screeching, barking grunting, or repetition of words or short phrases. 3 If YES to 1 or 2, do these tics interfere with the child's activities (like reading, writing, walking, talking, or eating)? Comments ASSESSMENT AND DIAGNOSIS ADD070 - Rev0115

Date: Child s Name: Date of Birth:

Date: Child s Name: Date of Birth: Dear Parent: Because ADD/ADHD is a chronic condition requiring ongoing medication, it is our policy to follow your child every 6 months to monitor his or her progress