ADHD Follow-up ADHD Follow-up Assessment ADHD Follow-up Assessment Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Today's Date * Patient Name * DOB * Parent/Guardian (If completing this for a minor) Current Pharmacy * Insurance (if changed from the last visit) Medication Are you currently taking ADHD medication? * Yes No Medication (or 'none') * Dosage * Time taken? * If, no, then why? (enter '-' if Not Applicable) * Is your medication taken daily (including weekends/holidays)? * Yes No If no, how often? (enter '-' if Not Applicable) * How long does the medication last? * Is the duration adequate to meet your daily needs? * Are you taking any other medication for anxiety or mood? * Name and Dose of over-the-counter medication taken on a daily basis? * Current Management Do you feel your ADHD symptoms are well controlled? Explain * Describe any concerns with your meds. * Anything else you'd like us to know? * Symptom Monitoring Please rate the symptoms listed below as one of the following: None, Mild, Moderate, or Severe. Headache * None Mild Moderate Severe Explain Irritability * None Mild Moderate Severe Explain Change in appetite * None Mild Moderate Severe Explain Dry mouth * None Mild Moderate Severe Explain Rapid heartbeat/palpitations * None Mild Moderate Severe Explain Tremors/Shaky feeling * None Mild Moderate Severe Explain Dull, tired, listless * None Mild Moderate Severe Explain Socially withdrawn * None Mild Moderate Severe Explain Hallucinations * None Mild Moderate Severe Explain Repetitive Movements (tics, twitching) * None Mild Moderate Severe Explain Picking or chewing at skin/nails/lips/cheek * None Mild Moderate Severe Explain Dizziness/High blood pressure * None Mild Moderate Severe Explain Depressed mood/Sadness/Suicidal thoughts * None Mild Moderate Severe Explain Difficulty sleeping * None Mild Moderate Severe Explain Anxiety * None Mild Moderate Severe Explain Date Submit If you are human, leave this field blank.
