ADHD Pre-Appointment Information · 1. PATIENT INFORMATION Patient Name (First name, middle initial and last name) Date of Birth Today’s Date Observer Name (First name, middle initial

Plaza Building, Suite 150 • Campus Box 20P.O. Box 173362 • Denver, CO 80217-3362

Phone 303-615-9999 • Fax 720-778-5850 • Web healthcenter1.com

HEALTH CENTER AT AURARIA

ADHD Pre-Appointment Information

ADHD General Information Attention Deficit Hyperactivity Disorder (ADHD) is a neurological condition that affects executive functioning in the brain. People with this condition can have problems with focus, concentration, hyperactivity and fidgeting that can lead to problems in school, work, relationships and social activities.

The cause of the disorder is not known. The disorder first manifests itself in childhood. Other conditions like depression and anxiety, as well as substance use, can mimic symptoms of ADHD. Individuals with ADHD, however, also have higher rates of depression, anxiety, substance use and some other co-existing conditions than individuals without ADHD.

ADHD Appointment Information If you have been diagnosed with ADHD and would like to transfer treatment to Health Center at Auraria, or if you have never been diagnosed, but would like to be evaluated for ADHD, the following paperwork is required to help facilitate your appointment.

Required Paperwork The following paperwork is required to be completed and brought to your first ADHD appointment. Additional paperwork will be completed upon arrival for the appointment.

ADHDPA032019

Patients with no established diagnosis of ADHD need to bring:

• ADHD Questionnaire: Patient• ADHD Questionnaire: Guardian/Childhood Observer• ADHD Questionnaire: Adult Observer• Stimulant Medication Policy

Patients who have been diagnosed in the past with ADHD but are not currently being prescribed stimulant medication need to bring:

• ADHD Questionnaire: Patient• ADHD Questionnaire: Guardian/Childhood Observer• ADHD Questionnaire: Adult Observer• Stimulant Medication Policy• Authorization to Release Protected Health Information from previous provider• Present documentation supporting the diagnosis of ADHD (testing results, records from the past provider)

Patients with an established ADHD diagnosis, currently being prescribed stimulant medication wishing to transfer their care to the Health Center at Auraria need to bring:

• ADHD Questionnaire: Patient• ADHD Questionnaire: Guardian/Childhood Observer• ADHD Questionnaire: Adult Observer• Stimulant Medication Policy• Authorization to Release Protected Health Information from previous provider• Present documentation supporting the diagnosis of ADHD (testing results, records from previous provider)• Transfer of Care form from the current prescribing physician

The evaluation can take two or more appointments. The provider can choose to contact the person who filled out the forms for more information between the appointments. The appointment is for an evaluation only and no guarantee is made that the provider will prescribe medication.



ADHD Questionnaire: Adult Observer 1. PATIENT INFORMATION

Patient Name (First name, middle initial and last name) Date of Birth Today’s Date

Observer Name (First name, middle initial and last name) Observer Phone Number Relationship to Patient

# How often does this person: NE

VE

R

RA

RE

LY

SO

ME

TIM

ES

OFT

EN

VE

RY

OFT

EN

1

have trouble wrapping up the final details of a project, once the challenging parts have been done?

Examples/Details:

2

have difficulty getting things in order when they have to do a task that requires organization?

Examples/Details:

3have problems remembering appointments or obligations?

Examples/Details:

4avoid or delay getting started when a task requires a lot of thought?

Examples/Details:

5

fidget or squirm with their hands or feet when they have to sit down for a long time?

Examples/Details:

6

seem overly active and compelled to do things, as if they were driven by a motor?

Examples/Details:

7make careless mistakes when they have to work on a boring or difficult project?

Examples/Details:

8

have difficulty maintaining attention when they are doing boring or repetitive work?

Examples/Details:

9

have difficulty concentrating on what people are saying, even when they are speaking to the person directly?

Examples/Details:


Please check the box which best describes you over the past 6 months. Provide examples/details when you rate a symptom as occurring “Sometimes”, “Often” or “Very Often”

# How often does this person: NE

VE

R

RA

RE

LY

SO

ME

TIM

ES

OFT

EN

VE

RY

OFT

EN

10misplace or have difficulty finding things at home or at work?

Examples/Details:

11get distracted by activity or noise around them?

Examples/Details:

12

leave their seat in meetings or other situations in which they are expected to remain seated?

Examples/Details:

13appear restless or fidgety?

Examples/Details:

14have difficulty unwinding and relaxing when they have time to themselves?

Examples/Details:

15talk too much when in social situations?

Examples/Details:

16

blurt out an answer before a question has been completed or finish other peoples sentences?

Examples/Details:

17have difficulty waiting their turn in situations when turn-taking is required?

Examples/Details:

18interrupt others when they are busy?

Examples/Details:

Is there any additional information that is relevant to this person’s ADHD assessment? If so, please describe below:

ADHDAO022019



ADHD Questionnaire: Guardian/Childhood Observer PATIENT INFORMATION


Observer Name (First name, middle initial and last name) Observer Phone Number Relationship to Patient

QUESTIONS

Do you feel that the above person had impairing issues with ADHD as a child?

If yes, then in which grade in school do you feel the problems started?

Did they receive additional help for ADHD?

If yes, by whom?

Did they receive educational testing?

If yes, by whom? Results of testing:

Is there a family history of ADHD or learning disabilities?

If yes, please describe:


YES NO UNSURE

YES NO UNSURE

YES NO UNSURE

YES NO UNSURE

#

When elementary school age, how often did the person being described…. N

EV

ER

RA

RE

LY

SO

ME

TIM

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OFT

EN

VE

RY

OFT

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1

not follow through on instructions and failed to finish schoolwork (not due tooppositional behavior or failure to understand)?

Examples/Details:

2have difficulty organizing tasks and activities?

Examples/Details:

3were forgetful in daily activities?

Examples/Details:

4

avoid, dislike, or was reluctant to engage in tasks that required sustained mental effort?

Examples/Details:

5fidget with hands or feet or squirmed in seat?

Examples/Details:

6were “on the go” or often act as if “driven by a motor”?

Examples/Details:

7not pay attention to details or make careless mistakes, for example homework?

Examples/Details:

8have difficulty sustaining attention to tasks or activities?

Examples/Details:

9not seem to listen when spoken to directly?

Examples/Details:

10lose things necessary for tasks or activities (school assignments, pencils, books)?

Examples/Details:

11were easily distracted by external stimuli?

Examples/Details:

Please check the box which best describes the person as a child between the ages of 7 and 11. Provide examples/details when you rate a symptom as occurring “Sometimes”, “Often” or “Very Often”. (Examples may include home, school or social environments.)


#

When elementary school age, how often did the person being described…. N

EV

ER

RA

RE

LY

SO

ME

TIM

ES

OFT

EN

VE

RY

OFT

EN

12leave seat when remaining seated was expected?

Examples/Details:

13run about or climb excessively in situations when remaining seated was expected?

Examples/Details:

14have difficulty playing or engaging in leisure/play activities quietly?

Examples/Details:

15talk too much?

Examples/Details:

16blurt out answers before questions had been completed?

Examples/Details:

17have difficulty waiting their turn?

Examples/Details:

18interrupt or intrude on others (i.e., butted into conversations or games)?

Examples/Details:


EX

CE

LLE

NT

AB

OV

E

AV

ER

AG

E

AV

ER

AG

E

SO

ME

WH

AT

OF

A P

RO

BLE

M

PR

OB

LEM

AT

IC

# Overall Performance (Ages 7 – 11) 1 2 3 4 5

19 Overall School Performance

20 Reading

21 Math

22 Written Performance

23 Relationship with Peers

24 Relationship with Parents

25 Relationship with Siblings

26 Participation in organized activities (i.e., teams)

ADHDGCO042019HEALTH CENTER AT AURARIA

DEVELOPMENTAL HISTORY

History of complications during pregnancy/delivery/1st days after birth?


Delivery was:

Number of days the person was in hospital after birth:

Was Neonatal ICU required?

At what age did they say their first words? At what age did they say their first sentences?

Any problems learning to read or write?

Did teachers ever express concern?

Any testing for speech, language, occupational therapy, or learning difficulties?

Any difficulty with scissors, eating utensils or holding a pencil?

Any history of heart disease for this person?

Other medical concerns?


Has the person ever fainted during exercise?


Have any family members died from sudden cardiac death before the age of 50?

Any history of neurological disorders such as seizures?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

VAGINAL C-SECTION

Is there any additional information that is relevant to the person’s ADHD Assessment? If so, please further describe:



ADHD Questionnaire: PatientPATIENT INFORMATION


Name/Location of High School Attended

Year of High School Graduation High School GPA Number of Semesters at College Current GPA

Number of Colleges Attended Current Major How many times have you changed your major?

Where do you live (on/off campus/with family)?

REASONS FOR THIS EVALUATION

Please list the symptoms and impairments that led you to seek an ADHD evaluation. If you have been diagnosed with ADHD in the past, list your current most impairing symptoms when off medication. Include details of your concerns and those expressed by others (professors, roommates, parents and other significant people in your life):

Have you ever been diagnosed with ADHD?If yes, how old were you?

Which type?

Who made the diagnosis?

Which of the following were involved in making the diagnosis of ADHD?

Have you ever been diagnosed with a learning disability?


YES NO

YES NO

ADHD, Inattentive predominant type ADHD, hyperactive-impulse predominant type ADHD, Combined Type

Psychologist Pediatrician Family MD

Clinical Interview & Observation

Psychoeducational or Neuropsychological testing

I am not sure about which type.

Checklist by you

Computerized testing

Checklist by parent(s)

Other:

Checklist by teacher(s)

Psychiatrist Other:

Please check the following items that were true for you for most or all of the time during each period:

ElementarySchool

MiddleSchool

HighSchool

Blurted out answers before questions were completed

Did not sustain attention to schoolwork during classes

Talked Excessively

Had trouble playing or doing leisure things quietly

Acted or spoke without thinking

Fidgeted or got out of seat excessively

Did not give close attention to details, made careless mistakes

Required disciplinary interventions, e.g. sat in front of the class

Had trouble organizing activities

Had problems with peers (e.g. difficulty waiting for turn)

Frequently lost things for tasks or activities (e.g. books, assignments)

Did not appear to be listening when spoken to

Failed to finish schoolwork and chores

Did just enough to get by

Describe details/examples of checked items in ELEMENTARY SCHOOL:

Describe details/examples of checked items in MIDDLE SCHOOL:

Describe details/examples of checked items in HIGH SCHOOL:

NO YES NOT SURE

History of thyroid disease?

History of head injury with loss of consciousness?

Current sleep disorder?

Trouble falling asleep?

Difficulty staying asleep?

Disrupted breathing or loud snoring during sleep?

Dozing off during the day?

Average amount of time before falling asleep? Average number of hours of sleep per night?

History of heart disease (palpitation, murmur, congenital heart disease)?


Have you ever fainted?

Family history of heart disease?


Have any family members died from heart disease before age 50?


Any family history of ADHD?

Any family history of learning disabilities?


Current medical illness(es), if any:

ALCOHOL AND DRUG USE

Do you use: (Check Yes or No in the right column) YES or NO If Yes, list past present (if present how many times a week).

Alcohol

Heroin

Methadone

Methamphetamines

Cocaine

Marijuana

Tobacco

Other:

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

DRIVING / LEGAL HISTORY

How many motor vehicle crashes have you been involved with as a driver?

In how many of these were you “at fault”?

How many of these were caused by being inattentive or distracted?

How many traffic tickets (not including parking tickets) have you received?

How many parking tickets?

Has your driver’s license ever been suspended? Number of DUI/DWAI Citations:

Have you had any legal problems other than a moving violation/traffic tickets in the past?

If yes, please describe and include date/age:

YES NO

YES NO

# How often do you... NE

VE

R

RA

RE

LY

SO

ME

TIM

ES

OFT

EN

VE

RY

OFT

EN

1

have trouble wrapping up the final details of a project, once the challenging parts have been done?

Examples/Details:

2

difficulty getting things in order when you have to do a task that requires organization?

Examples/Details:

3have problems remembering appointments or obligations?

Examples/Details:

4

avoid or delay getting started when you have a task that requires a lot of thought?

Examples/Details:

5

fidget or squirm with your hands or feet when you have to sit down for a long time?

Examples/Details:

6

feel overly active and compelled to do things, like you were driven by a motor?

Examples/Details:

7make careless mistakes when you have to work on a boring or difficult project?

Examples/Details:

8

have difficulty keeping your attention when you are doing boring or repetitive work?

Examples/Details:

9

have difficulty concentrating on what people say to you, even when they are speaking to you directly?

Examples/Details:

10misplace or have difficulty finding things at home or at work?

Examples/Details:

11get distracted by activity or noise around you?

Examples/Details:

12

leave your seat in meetings or other situations in which you are expected to remain seated?

Examples/Details:

13feel restless or fidgety?

Examples/Details:

Please check the box which best describes you over the past 6 months. Provide examples/details when you rate a symptom as occurring “Sometimes”, “Often” or “Very Often”

Is there any additional information that is relevant to the ADHD Assessment? If so, please further describe:

# How often do you... NE

VE

R

RA

RE

LY

SO

ME

TIM

ES

OFT

EN

VE

RY

OFT

EN

14have difficulty unwinding and relaxing when you have time to yourself?

Examples/Details:

15find yourself talking too much when you are in social situations?

Examples/Details:

16

blurt out an answer before a question has been completed or finish other peoples sentences?

Examples/Details:

17have difficulty waiting your turn in situations when turn-taking is required?

Examples/Details:

18interrupt others when they are busy?

Examples/Details:

Please list the medications you are currently taking or have taken most recently for ADHD.

Name of medication / maximum dose

How long & age(s) while taking?

Was it effective? What side effects?Why did you

stop taking this?

Check this box if you are currently taking additional medications not listed above.

Which emotional/behavioral health medications (like antidepressants, mood stabilizers) have been prescribed for you?

Name of medication / maximum dose

How long & age(s) while taking?

Was it effective? What side effects?Why did you

stop taking this?

Other past psychiatric history:

Have you ever been diagnosed with any of the following mental health conditions? NO YES NOT SURE

Depression


Anxiety Disorder


Bipolar Disorder


Other (If yes, please describe):

ADHDPO032019




Authorization to Release Protected Health Information

CONTINUING MEDICAL CARE INSURANCE LEGAL OTHER:

3. PURPOSE

As required by the Health Insurance Portability and Accountability Act of 1996, the Health Center at Auraria may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein. You may revoke this authorization at any time by signing and dating the revocation section on your copy of this form and returning to this office.

A copy of this authorization shall act as the original. I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected, excepting information protected by 42 C.F.R Part 2 Sub C § 2.32. which states: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that I may revoke this authorization at any time by signing the revocation section of my copy of this form and returning it to the office and address named above. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization. I understand that this authorization will automatically expire 1 year from the date of this document or_____________________ (Date of expiration). I understand that I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment, my eligibility for benefits, etc., will not depend in any way on whether I sign this authorization or not. I understand that I have a right to inspect and to obtain a copy of any information disclosed pursuant to this authorization. I understand that the Health Center at Auraria may receive compensation for the uses and disclosures that I have authorized.

Copy charges are as follows: Page(s) 1-11 provided at no charge, 12 pages for base fee of $10.00 plus additional $0.25 per page for page 13 and higher. An electronic copy is available at a flat fee starting at $10.00. ________ Please check here to request an electronic copy.

I authorize the following persons/agency to send and/or receive these disclosures of my health information:

_____ Initial here for reciprocal communication, written and/or verbal, between the providers named below.

4. RELEASE RECIPIENT INFORMATION

Name Name

Current Address (Number, street & apt or suite number) Current Address (Number, street & apt or suite number)

City State Zip Code City State Zip Code

Phone Number Fax Number Phone Number Fax Number

**REVOCATION SECTION: I hereby revoke this authorization by signing below. Date

Patient Signature Date

Your request is granted. We will send the information you requested with fifteen (15) days of our receipt of your payment of $_____________.

Your request is denied.

1. PATIENT INFORMATION

Patient Name (First name, middle initial and last name) Date of Birth

Social Security Number Student/Staff/Faculty ID# Phone Number

Current Address (Number, street & apt or suite number) City, State and ZIP Code Email Address

2. RECORDS FOR RELEASE (Please initial the records to be released)

TO TOFROM FROM

_________ ALL RECORDS (Including Psych/STD/HIV/Substance Abuse)

_________ PSYCHIATRIC/PSYCHOLOGICAL

_________ SUBSTANCE ABUSE (42.C.F.R PART 2)

_________ STD/HIV TESTING

_________ MEDICATIONS

_________ LAB RESULTS

_________ OTHER:

_________ IMMUNIZATIONS

_________ IMAGING REPORTS/X-RAYS

ARPHI012019

Health Manager Signature Date

Documents

ADHD Pre-Appointment Information · 1. PATIENT INFORMATION Patient Name (First name, middle initial and last name) Date of Birth Today’s Date Observer Name (First name, middle initial