Child Patient Paperwork

Please correct the errors described below.

Step 1: ADHD Child 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.


Primary/Parent Guardian

Other Parent/Guardian

Patient Address


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

Step 2: Patient Health History

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

Birth and Development

Patient Illnesses

For items below include reason, dates and duration

Family History

Family Mental Disorder

Patient Social History

Describe: beer, wine, hard alcohol including volume per day usage.

Describe: cigarettes, cigars, snuff, chew, quantity per day usage and dates.

Have you had previous ADHD Treatment

If "Yes" above complete the following information.

Previous Treating Physician

Current Treating Physician

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