ADD/ADHD Assessment. for patients age 18 years or older. Name: Date of Birth: Age: Sex: Today s Date:
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1 Lisa Sachdev, D.O. ADD/ADHD Assessment for patients age 18 years or older In order for us to be able to fully evaluate you, please fill out the following questionnaire to the best of your ability. We realize there may be information that you do not remember or have access to; do the best you can. Thank you! PATIENT IDENTIFICATION Name: Date of Birth: Age: Sex: Today s Date: Current Marital Status- Single Engaged Married Living together Separated Divorced (# of times divorced = ) Members of your household include- REFERRAL SOURCE - How did you find out about our clinic? Referred by a friend, family member or co-worker Referred by a physician or mental health professional Found the clinic via an Internet search for ADHD evaluation and management Other: (please explain) What are your goals in seeking this consultation? What do you hope to gain? Page 1 of 8
2 YOUR FAMILY HISTORY Natural Mother s History- Age: Employed as: School- highest grade completed: Learning problems (specify): Marriages: _ Has mother ever sought psychiatric treatment? Yes No If yes, for what purpose? Mother s alcohol/drug use history: Natural Father s History- Age: Employed as: School- highest grade completed: Learning problems (specify): Marriages: _ Has father ever sought psychiatric treatment? Yes No If yes, for what purpose? Father s alcohol/drug use history: Your Siblings- Please list their names, ages, academic and/or employment success or problems, and any history of substance abuse or criminal activity. Page 2 of 8
3 Your Children Please list their names, ages, academic, behavioral, emotional or developmental problems: YOUR EDUCATIONAL HISTORY Last grade completed: Last school attended: Average grades received: Any academic problems: Learning strengths: Any behavior problems in school? Elementary, Intermediate and High School: (please check all that apply) Special education classes Resource classes Tutoring provided by the school Repeated a grade level: level(s) repeated: voluntary mandated Attended summer school: number of summers attended Advanced placement (tested out of classes or a grade level) Pre-AP classes AP classes Dual credit classes (received both high school and college credits) Gifted and talented classes or curriculum Alternative school or curriculum Charter school attendance Private school attendance Homeschool attendance High School: Received diploma: Received GED: Dropped out in the grade Page 3 of 8
4 College: # of years attended: Field of study: (highest degree earned) Technical certificate Associate s degree Bachelor s degree Master s degree Doctorate degree Other degree (details) YOUR EMPLOYMENT HISTORY Your current employment status is best described as: (check any that apply) working part-time working full time temporary employment retired seeking employment working more than one job homemaker disabled recently hired recently promoted recently terminated recently reprimanded Name of your current employer: Job title: When hired: (month/year): Please explain your work schedule: (days, nights, shift work, weekends, on-call, hours, etc.) Please list any recent changes in your work responsibilities or environment: Military History: Any Legal Problems? Page 4 of 8
5 CURRENT LIFE STRESSERS Is there anything that is or has recently been stressful for you? Examples include job changes, school, finances, children or siblings, marriages, separations, divorces, death, traumatic events, losses, abuse, legal problems, physical ailments, etc.) ALCOHOL AND DRUG USE HISTORY Please list age started and types of substances used through the years and any current usage. Also, describe how each of the substances made you feel; what benefit you got from them. These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc), cocaine or crack, amphetamines, crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms), PCP, etc. (list these on the next page) Caffeine use per day (caffeine is in coffee, tea, sodas, energy drinks, chocolate, etc.) Nicotine use per day, past and present (nicotine is in cigarettes, cigars, tobacco chew, etc.) Page 5 of 8
6 PAST MEDICAL HISTORY: (please mark each item) Medical condition or symptom Attention deficit disorder (ADD or ADHD) Seasonal allergies Asthma Eczema Gastrointestinal problem Food intolerance or allergy Seizures/convulsions/epilepsy Attention deficit disorder (ADD or ADHD) Seasonal allergies Asthma Eczema Heart problems Restless legs symptoms (RLS) Recurrent headaches Thyroid disorder Sleep apnea Insomnia Vitamin deficiency Premenstrual Syndrome (PMS) Menopausal symptoms Irregular menstrual cycle Testosterone deficiency Dyslexia Dyscalculia Vision problems Hearing problems Does not apply Currently Previously Family History Page 6 of 8
7 Medical condition or symptom Anxiety Bipolar disorder Anger disorder Conduct disorder Oppositional defiant disorder Schizophrenia Does not apply Currently Previously Family History If there are any other health conditions or symptoms that you would like to mention please list them below. If you need to explain any items above please elaborate below. PREVIOUS PROVIDERS WHO MAY HAVE EVALUATED OUR MANAGED ADD OR ADHD FOR YOU: Please list any physicians, mental health providers, counselors, therapists or life coaches that are currently being used or were used in the past. If there were problems with previous providers, including their office staff or policies please describe them below. PAST TREATMENTS: Please list any prescription medications, supplements or other treatments that have been tried to improve attention and/or decrease hyperactivity. Include as much detail as possible including whether or not the treatment helped and any side effects or problems experienced with the treatment. Are the treatments still being used? If not, why were they stopped? Page 7 of 8
8 ADULT RATING SCALE 2 Below is a list of behaviors or problems that some people have. To the right of each item indicate, in your opinion, how much of a problem each one is for you WITHOUT medication for ADD or ADHD management. Please be sure to provide an answer to each question. 1. Physical restlessness, excessive fidgeting 2. Difficulty concentrating 3. Easily distracted 4. Impatient 5. Hot or explosive temper 6. Unpredictable behavior 7. Shifts often from on uncompleted task to another 8. Difficulty completing tasks 9. Impulsive 10. Talks excessively 11. Often interrupts others 12. Often loses things 13. Forgets to do things 14. Engages in physically daring activities, reckless 15. Always on the go, difficulty sitting still 16. Does not appear to listen to others when spoken to 17. Difficulty sustaining attention 18. Difficulty doing things alone 19. Frequently gets into trouble with the law 20. Difficulty delaying gratification 21. Lack of organization skills 22. Inconsistent work/school performance 23. Inability to establish and maintain a routine 24. Performing below level of competence in work/school 25. Overexcitability Not at all Just a little Pretty Much Very Much Lisa L. Weyandt, Ph.D., Central Washington University, Ellensburg, WA (509) Ext 36 THANK YOU FOR COMPLETING THIS PAPERWORK Page 8 of 8
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