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Health History
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Medical Providers Visit Frequency:
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Active medical concerns:
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Ever had COVID-19 Symptoms:
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Surgical History:
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Current Medications
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Vitamins / Supplements
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Drug Allergies
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Previous Diagnoses an ADHD
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Highest level of education:
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Type of school attended:
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Required to repeat a grade:
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IEP / accommodations:
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Feedback from teachers:
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Past meeting with a therapist:
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Current meeting with therapist:
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Previously tried medications:
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Birth mothers' pregnancy complications
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Other comments related to birth history:
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Early childhood development comments:
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Family History
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Is family history known:
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Relatives with ADHD:
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Relatives with Anxiety:
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Relatives with Depression
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Relatives with Bipolar:
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Relatives with Schizophrenia:
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Relatives with ETOH abuse:
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Relatives with SUD:
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Relatives with OCD:
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Relatives with Autism:
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Lifestyle
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Weekly Diet:
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Consumption of energy drinks:
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Regular meals:
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Consumption of caffeine:
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Home environment:
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Lives in:
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Lives With:
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Pets in the home:
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Spiritual faith / religion in the home:
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Time spent with faith:
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Involved in creative arts:
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Involved in sports:
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Involved with music:
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Socialization:
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Smoking status:
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Alcohol:
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Recreational Drugs
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Hours of sleep per night:
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Wake feeling rested:
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Wake daily on average:
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Time to fall asleep:
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Interrupted sleep:
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Average times awakening nightly:
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Ease of returning to sleep:
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Personal Characteristics
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Self-assessed Personality traits:
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Personality traits described by others:
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Difficulty expressing emotion:
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Bothersome sensory experiences:
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Primary reason for evaluation
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Main concerns and symptoms:
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Reason for seeking evaluation:
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Symptom severity
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Primary relationships impacted:
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Financial impact:
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Social impact:
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Communal/faith-based impact:
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Job performance impact:
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Sports or recreations impact:
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History of inattention and/or hyperactivity
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Symptoms experienced 12 years old or younger
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How far back do the symptoms go:
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How long have symptoms been present:
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Time of day symptoms are present:
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Stressful events in the last 9 months
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Stressful events longer than 9 months
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Anxiety Symptoms w/in last 9 months
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Depression symptoms w/in last 9 months
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Emotional response to the stress w/in the last 9 months
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Trauma and risk
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History of physical abuse:
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History of mental abuse:
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History of sexual abuse:
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Current physical abuse
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Current mental abuse:
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Current sexual abuse:
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Traumatic life events experienced:
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