ADHD Medication Follow-up

Please circles yes or no questions about your child's symptoms. Please answer to the best of your ability.

Date of Today

Patient Name

Date of Birth

Accompanied By

Inattentive Symptoms

Easily distracted?

Yes No

Forgetfulness?

Yes No

Make careless mistakes?

Yes No

Poor follow through/task completion? (i.e. homework or projects)

Yes No

Poor attention to detail?

Yes No

Poor concentration?

Yes No

Academic underachievement? (i.e. do you think your child could be doing better)

Yes No

Problems with disorganization?

Yes No

Hyperactivity-Impulsivity Symptoms

Excessively fidgety?

Yes No

Difficulty staying in seat?

Yes No

Talk excessively?

Yes No

Difficulty playing quietly?

Yes No

Restlessness/always "on the go"?

Yes No

Disruptive classroom behavior?

Yes No

Blurts out answers too quickly?

Yes No

Difficulty awaiting turn?

Yes No

Interrupts or intrudes on others?

Yes No

Were your child's symptoms present before age 7?

Yes No

Are your child's symptoms present in two or more settings? (i.e. home and school)

Yes No

Subjective:

ADHD control status (i.e. Is your child doing better or worse with the medication they are on)?

Stable

Improving

Getting Worse

Mildly Improving

Are you satisfied with your child's current medication or therapy?

Yes No

Medication compliance? (i.e. Does your child take the medication everyday as prescribed)

Yes No

Initial ADHD evaluation completed?

Yes No

Does your child take medication on weekend/vacations?

Yes No

Work/School Performance?

Average Excellent Fair Poor

School Performance

Work/School Performance?

A's & B's B's & C's C's & D's Failing current grade

Are there any other concerns about your child that you would like to discuss with the provider?