ADHD Medication Form

Date:

PLEASE LIST YOUR PREFERRED PHARMACY

ADD Medication Request

Please allow 48 hours for prescription to be ready for pick-up- The RX does expire 21 days from the date we write it - if another RX has to be written due to expiration a $10 free will apply.

Patient Name:

Age:

Date of Birth:

Strret Address:

City:

St:

Zip:

Name of Medication:

Strength(mg):

Add new row

Amount of Medication Needed (number of tablets):

Generic

or Brand:

If any of the above apply please describe how often and when these events occured:

Have you spoken with the child's teacher lately:

How is the child performing in class:

Did your child complain about taking the medication or avoid its use:

How is homework and family time in the evening?

Does the medication seem to be helping the child as much this month as it did last month

If not, what seems to have changed:

Have there been problems giving the medication at school or at home:

When was your child last seen in this office for an ADD check:

Verified:

It is important for patients on medications for ADD to receive growth evaluations. We check these patients every 6-months for growth including a complete well check-up once a year. If your child is due for such a check-up, please schedule an appointment. If these appointments are not kept, we will not continue to fill the medication.

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