Child Patient Paperwork

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.

Child's First Name & Last Name

Age

Patient Date of Birth

Please describe the issues your child is having.

How are these issues affecting his/her and your life?

CONTACT INFORMATION

Primary/Parent Guardian

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First Name

Last Name

Phone

Email address

Street Address

Apt, Suite, etc.

City

State

ZIP/Postal Code

INSURANCE INFORMATION

Insurance Self Pay

Card ID (front)

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Card ID (back)

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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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