ADHD Medication Initial Evaluation

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

School Performance: Select one of the following

Average grades?

Average Doing Well No Concerns Struggling in School

Anxiety Disorder Symptoms

Excessive worrying?

Yes No

Irritability?

Yes No

Sweating?

Yes No

Nausea?

Yes No

Palpitation? (i.e. heart fluttering)

Yes No

Hyperventilation?

Yes No

Panic attacks?

Yes No

Agoraphobia? (i.e. fear of large open areas/crowds)

Yes No

Obsessive behavior? (i.e. distress, anxiety, disturbance or child's daily routine)

Yes No

Compulsive behavior? (performing an action persistently and repetitively without necessarily leading to an actual reward or pleasure)

Yes No

Depressed mood?

Yes No

Anxious mood?

Yes No

Oppositional defiant symptoms? (i.e. angry/vindictive/easily annoyed)

Yes No

Conduct disorder symptoms? (i.e. aggression/destructive/deceitfulness)

Yes No

Health Maintenance

Anhedonia? (i.e. the inability to feel pleasure)

Yes No

Significant weight loss/gain?

Yes No

Insomnia? (i.e. common sleep disorder that can make it hard to fall asleep, hard to stay asleep)

Yes No

Hypersomnia? (i.e. excessive daytime sleepiness or excessive time spent sleeping)

Yes No

Psychomotor retardation? (i.e. a slowing down of thought and a reduction of physical movements in an individual)

Yes No

Fatigue/Loss of energy?

Yes No

Feelings of worthlessness?

Yes No

Feeling of guilt?

Yes No

Impaired concentration/indecisiveness?

Yes No

Suicidal thoughts?

Yes No

Are there any other concerns you would like to discuss with the provider?

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