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

Primary Parent/Guardian First & Last Name

Relationship to Patient

Primary Parent/Guardian Date of Birth

Phone

Email address

Primary Parent/Guardian’s Marital Status

Does the child live with this parent/guardian?

Other Parent/Guardian

Other Parent/Guardian First & Last Name

Relationship to Patient

Patient Address

Street Address

Apt, Suite, etc.

City

State

ZIP/Postal Code

INSURANCE INFORMATION

Insurance

Effective Date

Group #

Member ID

Payor ID

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

Policyholder's Name

Policyholder's Date of Birth

Relationship to Patient

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

Height

Weight

Known drug allergy

Current Long Term Meds

Birth and Development

Patient Illnesses

Lung Disease

Explain "Yes" response above

For items below include reason, dates and duration

Hospitalized

Surgeries

Psychiatric Hospitalization

Other Serious Illnesses

Family History

Family Mental Disorder

Patient Social History

Siblings

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

Alcohol Use

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

Tobacco

Have you ever been arrested/charged/incarcerated for alcohol/drug abuse or “any” other illegal behavior?

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

Previous Treating Physician

Name (details otherwise none)

Telephone (details otherwise none)

Address (details otherwise none)

Current Treating Physician

Name (details otherwise none)

Telephone (details otherwise none)

Address (details otherwise none)

Email address

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