Adult Patient Paperwork

Step 1: ADHD Adult Test

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.

Patient First Name & Last Name

Age

Patient Date of Birth

Please describe the issues you are having?

How are these issues affecting your life?

CONTACT INFORMATION

Upload Photo ID

Add file

Please upload a file

First Name

Last Name

Phone

Email address

Street Address

Apt, Suite, etc.

City

State

ZIP/Postal Code

INSURANCE CARD

Insurance Self Pay

Card ID (front)

Add file

Please upload a file

Card ID (back)

Add file

Please upload a file

Add new row

Have you had previous ADHD Treatment

If "Yes" above complete the following information.

Years on treatment:

Are you still currently receiving treatment?

Reason for stopping meds.

Side Effects

Cost

Ineffective

Other

Didn't Need

Other Specified

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