ADHD Follow-Up Questionnaire

Today's Date

Patient Name

Date of Birth

Form Filled Out By

Is your child’s medicine helping?

Yes No

Do you want to continue the current medicine(s)?

Yes No

Attention at Home

Same Improved Worse

Attention at School

Same Improved Worse

Hyperactivity

Same Improved Worse

Conduct

Same Improved Worse

Organization

Same Improved Worse

What time does your medicine stop working?

Does your child take meds on weekends? holiday?

Are you concerned with your child’s appetite and when?

Irritability

Trouble Falling Asleep

Headaches

Stomach Aches

Loss of Appetite

Weight Loss

Is your child getting any special help/services at school?

Yes No

If yes, please describe

School Name

Grade