ADHD Evaluation Family Version ADHD FAMILY VERSION Date* MM slash DD slash YYYY Your Name* First Last Relationship Patient's Name* First Last This form will be completed from observational point of view as follows:*Past 6 months from close household relationshipHistorical view of childhood or adolescence from parent or guardianSecondary observations from Therapist, providersOther:Do you have any concerns about the basic health and functioning of the patient (Rest, sleep, nutrition, mental acuity, daily coping?)Please describe symptoms and impairments that you hope to have the ADHD evaluation address for this patient:Do you have any concerns about use, misuse or dependence on the following?Caffeine, energy drinksAlcoholCannabisIllicit drugsSocial Media/device dependencePrescription DrugsVideo GamingNoneOtherHas this patient ever been diagnosed with ADHD? Yes No Unknown If previously diagnosed with ADHD, who made the diagnosis?PediatricianNeuropsychologist with testingOffice Interview, PsychiatristOffice Interview, Psychologist or other Mental Health providerPrimary Care PhysicianN/AIf known, has the patient been prescribed medication for ADHD (ex. Vyvanse (Lisdexamphetamine), Adderall (Mixed amphetamine salts), Strattera (atomoxtine), etc)?As child or adolescent, was the patient ever diagnosed or tested for any of the following?UnknownReading problem or delayDyslexiaMath problemExecutive function problemAuditory processing problemNon verbal learning disabilityOtherHas the patient had any of the following?UnknownAccidents where they have been the driverLegal problemsAcademic delay, dysfunction, probationOccupational problemsNone of the aboveOther1) How often has the patient failed to give close attention to details, or made careless mistakes in schoolwork, at work or during other activities (e.g. overlooking or missing details, work is inaccurate)? Never Rarely Sometimes Often Very Often Unknown 2) How often has the patient had difficulty sustaining attention in tasks or leisure activities? Do they have difficulty remaining focused in lectures, conversations or with lengthy readings? Never Rarely Sometimes Often Very Often Unknown 3) How often have they not been listening when spoken to directly? (i.e. like their mind being somewhere else?) Never Rarely Sometimes Often Very Often Unknown 4) How often have they not been following through on instructions and failing to finish schoolwork or duties at the workplace (e.g. starting a task but losing focus and being easily sidetracked)? Never Rarely Sometimes Often Very Often Unknown 5) How often have they been having difficulty organizing tasks and activities (e.g. disorganized at work or school, poor time management, missing deadlines)? Never Rarely Sometimes Often Very Often Unknown 6) How often has the patient been avoiding, disliking or been reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork, preparing assignments)? Never Rarely Sometimes Often Very Often Unknown 7) How often has the patient been losing things needed for tasks or activities (e.g. school material, keys, wallet, etc.)? Never Rarely Sometimes Often Very Often Unknown 8) How often were they easily distracted by extraneous stimuli? Never Rarely Sometimes Often Very Often Unknown 9) How often were they forgetful in daily activities (e.g. when doing chores or errands)? Never Rarely Sometimes Often Very Often Unknown 10) How often did the patient fidget or tap their hands or feet or squirm in their seat? How often have you had to help the patient to channel or contain their energy (beyond what is typical for children)? Never Rarely Sometimes Often Very Often Unknown 11) How often did they leave their seat in situations where remaining seated was expected (e.g. in the classroom)? Never Rarely Sometimes Often Very Often Unknown 12) How often did the patient run about or climb in situations where it was inappropriate? Never Rarely Sometimes Often Very Often Unknown 13) How often were they unable to play or engage in leisure activities quietly? Never Rarely Sometimes Often Very Often Unknown 14) How often were they ‘on the go,’ acting as if ‘driven by a motor’? Never Rarely Sometimes Often Very Often Unknown 15) How often did the patient talk excessively? Never Rarely Sometimes Often Very Often Unknown 16) How often did they blurt out an answer before a question was completed, or could not wait your turn in conversation? Never Rarely Sometimes Often Very Often Unknown 17) How often did they have difficulty waiting for their turn (e.g. while waiting in line)? Never Rarely Sometimes Often Very Often Unknown 18) How often did they interrupt or intrude on others (e.g. butted into conversations, games, activities, or used other people’s things without receiving permission)? Never Rarely Sometimes Often Very Often Unknown From the 18 items listed above, please give examples of the items marked as ‘often’ or ‘very often’ FROM YOUR HISTORICAL VIEW (OR THE PAST 6 MONTHS). Add if these are occurring at home, work or school.Is there any history of ADHD or learning disabilities in the family? If so, in whom was it diagnosed or assumed?If known, did teacher(s) ever express concerns?Please check if the patient is known to have had any of these:Diagnosed structural problems with your heartFainting during exerciseTic disorderTourette'sSeizuresChronic difficulty with sleepFamily history of bipolar disorder (manic depressive episodes)Family history of heart diseaseElevated blood pressure that is not well controlledHave there been any family members who have died from sudden cardiac arrest before the age of 50? Yes No Please upload any psychological testing, neurology reports, diagnostic tests, report cards, teachers reports that will be helpful in arriving at an accurate diagnosis. Drop files here or Select files Max. file size: 666 MB. Principles of Treatment with Psychostimulants For Review Only• Exploring medication treatment is possible with proper referral: o Referral by a qualified therapist. Often, attentional problems can be situational or related to anxiety, depression or some other underlying disorder. Medication should be a recommended additional step AFTERr other treatments have been thoroughly explored. OR o Referral by a qualified Neuropsychologist who has conducted neuropsychological testing can help in determining the diagnosis. o Primary Care Physician referral o Diagnosed treatment and testing as a child, generally under the age of 12. As a condition of treatment, I require a referral by a qualified therapist with experience in treating attentional disorders these conditions prior to engaging in medication treatments. Therefore, referral by a qualified therapist for attentional assessment and treatment is key. • Psychological dependence can develop with prescribed attentional medications. Situations where medication must be stopped, or interrupted (illness, pregnancy, medication shortages, prescriber availability, pharmacy or insurance changes, etc) must be anticipated and expected. • Other strategies must be employed both during and in the absence of medication treatment. These strategies can be behavioral, technological, organizational, etc. and may involve lifestyle changes. Academic or career coaching should also be considered as part of a comprehensive plan for treatment. • For Students: Studies have shown that using stimulants solely as a study aid does NOT improve a student’s overall academic functioning. Those who misuse stimulants are likely to have LOWER GPAs and more likely to have an alcohol use disorder. • Feeling more productive after taking a friend’s stimulant is NOT a sign of ADHD. Neither is it a sign that stimulants are the appropriate treatment. A person without ADHD may subjectively FEEL that he or she is functioning better on stimulants even though objectively he or she may NOT be functioning better. • Stimulants have a high potential for abuse and use can lead to severe psychological and/or physical dependence, sometimes can lead to the development of other substance abuse disorders. Because of this, the FDA has classified stimulants as a Schedule II controlled medication (same schedule as oxycodone and fentanyl). • If prescribed, stimulants should only be obtained from one clinician. Clients need to attend regular visits with their clinician in order to receive prescriptions (Usually each 30 – 60 days by law). • Prescribing laws vary from state to state. Prescribing medications to other state pharmacies is often not possible due to licensing restrictions. • Most states are moving to electronic prescriptions and eliminating paper prescriptions, If prescriptions are called to you’re your pharmacy and post dated for the next month you will have to call the pharmacy to have the prescription filled. Pharmacies will not automatically fill the prescription unless you call to activate the fill request. • Stimulant prescriptions will not be renewed if lost, stolen, or for spillage. If you are traveling, pharmacies will not refill the prescriptions earlier then the earliest fill date. (usually 30 days) • Even if you have been prescribed stimulants for the treatment of ADHD, using stimulants for other purposes is considered stimulant abuse. Examples would include the use of stimulants to stay awake to study at night, or recreational use to obtain a high. • Stimulants should never be combined with alcohol, cannabis or other substances. Combining these with stimulants can prolong time spent engaging in drug or alcohol use, lead to dehydration, seizure, paranoia, psychosis, panic/anxiety attacks or other dangerous consequences. • Diversion of stimulants to others is illegal (i.e. a felony) and dangerous. There are serious medical risks to sharing stimulants with others. Some people have undiagnosed risk factors, can develop symptoms of mania, psychosis or heart problems that can lead to death.