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Transcription:

ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Email address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary Care Physician: Tel: Reason For Your Visit: What are your specific goals for ADHD Treatment (improve/fix what) 1. 2. 3. 4. HPI (doctor to compete this section): Hyperactivity (Fidget/restless/motion/loud/drive/talk/speak/waiting/intrude): Inattention (details/attn./listen/finish/org/delay/lose/forget/distract): Family: School/Work: Childhood: Legal/discipline: 1

Patient to Complete From Here to the end Drug Use History : Do You Smoke or Use Tobacco Products? When was your last alcoholic drink? In the past 30 days, about how many of those days have you had at least one alcoholic drink? What is the maximum number of drinks you have had in one day in the past month? DUI DWI Public Intoxication Seizures DT s Rehab Please check the appropriate boxes that apply to you for the following substances: Never Used Age first used Age it became a problem Age and peak use amount Lase use Current use and frequency Alcohol Amphetamine/Stimulants Marijuana/spice/synthetic Marijuana Cocaine Hallucinogens (LSD,mushrooms, Mescaline) Benzodiazepines (xanax, valium, ativan Restoril, Librium) Club Drugs Inhalants-gas/glue Bath Salts Ecstasy PCP or Angel Dust IV Drug use GHB Other: 2

Previous Treatment Please list any inpatient mental health hospitalization Hospital name/dates/reason _ Previous Outpatient Psychiatric History: Have you ever been treated for any of the following by either a family doctor or psychiatrist (check all that apply), if so, please list medications given: Depression ADHD Bipolar (Manic / Depressive) Disorder Anxiety OCD Schizophrenia Panic Attacks PTSD Alcohol Problems (including AA) Anorexia/ Bulimia Binge-eating Drug Problems ECT treatment Current and Previous MEDICAL Problems (Check all that apply High Blood Pressure Diabetes Heart Attacks Strokes Hepatitis Asthma Thyroid Sleep Apnea COPD Seizures Sexual Disease Heart Failure Hepatitis HIV Fibromyalgia Hysterectomy Tubal Ligation Migraines Urinary Cancer Bleeding Problems GI Problems Head Injury Kidney Cholesterol Last menstrual period (if applicable) Contraceptive method: List all prior surgeries and hospitalizations for MEDICAL illnesses Please List all current medications below (include birth control pills, over the counter medication and herbal remedies (i.e. decongestants, St. John s Wort etc) 1. 2. 3. 4. 5. 6. Allergies (Medication/Food): _ Family History: Has anyone in your family ever been treated for any of the following (please check all that apply and when appropriate indicate paternal or maternal) 3

Father Mother Aunt Uncle Brother Sister Children Grandparent Depression Anxiety Panic Attacks Post-traumatic stress Bipolar/Manic depression Schizophrenia Alcohol Problems Drug problems ADHD Suicide attempts Psychiatric hospital stay What MEDICAL Problems run on one or both sides of the family? (Diabetes, High Blood Pressure, etc) Social History: -Where were you born and raised? -Who raised you; your home life growing up? -How many siblings and what was your family like growing up? -Highest level of education -Marital status? -Your current living situation -Anyone in the home using drugs/alcohol? -Employment/length or employment? -Do you receive disability? -An history of physical or sexual abuse? -Who is your main emotional support? -Plans over the next year? -Have you ever been in jail or prison other than earlier noted? 4

Review of Systems: (please circle all that apply) General: Recent weight loss, recent weight gain, weakness, fatigue, night sweats, fevers Eyes: Double vision, blurred vision Ears, nose, throat: Dry mouth, hoarseness, difficulty swallowing Respiratory: Cough, sputum, shortness of breath at rest, shortness of breath with activity Cardiovascular: Heart trouble, chest pain or discomfort, palpitations Gastrointestinal: Ulcer, trouble swallowing, heartburn, change in appetite, nausea, diarrhea, constipation, rectal bleeding Urinary: Increased frequency of urination, incontinence, problems with urination Musculoskeletal: Muscle or joint pain or stiffness, joint pain, redness, swelling Psychiatric: Anxiety, depression, mood unstable, suicidal thoughts Neurologic: Headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, numbness or loss of sensation, tremors or other involuntary movements, seizures MSE/Impression: See face sheet Patient Signature Date: 5

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