This test is not a comprehensive list of questions, but will give a good indication to the doctors whether further testing is needed to confirm ADD/ADHD symptoms.
The member ID is the unique ID your insurance company uses to identify your account. May also be called Member ID
The payor ID is generally a 5 digit number that is unique to each insurance company.
By completing the following health history survey the doctor will have the necessary information to proceed with diagnostics/treatment. Please complete all fields to the best of your knowledge.
Leaving areas with “Select One” as your answer will invalidate your submission
Describe: beer, wine, hard alcohol including volume per day usage.
Describe: cigarettes, cigars, snuff, chew, quantity per day usage and dates.
If "Yes" above complete the following information.
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