Download ADHD Pre-Appointment Documents

Washington University
Habif Health and Wellness Center
314-935-6695
ADHD Pre-Appointment Documents
The following packet MUST be completed prior to our scheduled appointment.
Please fill out the questionnaires and return them at least ONE WEEK before your appointment
otherwise your appointment will be cancelled and need to be rescheduled. You will be sent a
reminder email.
If you have been previously diagnosed with ADHD, you will need a copy of any psychological
testing as well as a letter/record from your most recent prescribing physician with
documentation of diagnosis, medication, and dose. If you do not have copies of these records,
a release of information form will need to be completed so we can access this information.
Please note that having a previous diagnosis does not automatically mean you will meet
diagnostic criteria currently.
Sometimes other mental health concerns (e.g., feeling depressed, using alcohol) can mimic the
symptoms of ADHD. If you have received assistance for any mental health concern or
substance abuse issue (currently or in the past), we will need a copy of those records (e.g.,
treatment summary from your counselor/psychiatrist). If you do not have copies of these
records, a release of information form will need to be completed so we can access this
information.
Additional information from someone who knew you well as a child may be needed to
determine a diagnosis (e.g., parent, grandparent, teacher). If this is the case, we will need to
ask you to complete a release of information for someone who knew you well as a child.
If an accurate diagnosis cannot be determined after evaluating your information and meeting
with the psychiatrist, further evaluation outside of the Student Health Service may be required.
Your doctor will determine whether this is the case.
Please call if you have any questions or need assistance with completing this information.
ADULT GENERAL SYMPTOM INVENTORY
Instructions: Rate each statement by placing the appropriate number corresponding to how you feel
about the statement in the space to the left of each item. If an item does not apply to you, write NA for
“not applicable.”
01234NA
This statement does not describe me at all.
This statement describes me to a slight degree.
The statement describes me to a moderate degree.
The statement describes me to a large degree.
The statement describes me to a very large degree.
Not Applicable
IMPULSIVITY/SELF-CONTROL
____
____
____
____
____
____
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____
I tend to “go with my feelings” and often don’t think before I act.
I interrupt others in conversation.
Sometimes I hurt people’s feelings without meaning to because I speak before I think.
I “got in trouble” in school for talking or misbehaving.
I am a risk taker.
I make decisions quickly.
When I have a job to do, I just dive in and figure it out as I go.
I have had more than my share of speeding tickets or car accidents.
HYPERFOCUSING
____
____
Sometimes I become so involved in what I’m doing that I completely lose track of time.
When people talk to me or call me when I’m engrossed in something, I frequently don’t hear the
them.
TIME MANAGEMENT
____
____
____
____
____
____
I have trouble being “on time.”
I tend to procrastinate.
I am unrealistic about how long a task will take.
I tend to make too many commitments.
I am often late for appointments or meetings.
No matter how good my intentions are, I end up (or used to end up) doing “all-nighters” before
exams.
SELF-DISCIPLINE
____
____
____
____
____
I have difficulty sticking to my plans for “self-improvement”.
I can’t tear myself away from activities I like, even when I know I will be late for something.
I usually do what I like, and put off things that I ought to do.
The only way I can get myself to do boring projects or tasks is to wait until the deadline.
I have started and dropped many interests.
____
____
I have been called lazy.
I have been called irresponsible.
SLEEP/AROUSAL PROBLEMS
____
____
____
____
____
____
____
I have very irregular sleep patterns.
Falling asleep at night has always been difficult for me.
I am a restless sleeper.
It is hard for me to wake up in the morning.
I often oversleep.
When sitting in class or studying, I quickly feel tired, mo matter how much sleep I got the night
before.
I tend to fall asleep for catnaps if I sit down or lie down to relax.
ORGANIZATION/STRUCTURE
____
____
____
____
____
____
____
____
____
I rarely plan my day.
I tend to be messy.
Other people have complained about my disorganization or messiness.
I have trouble keeping up with several simultaneous projects.
I have become overwhelmed when I have too many choices.
I have trouble managing money.
I have difficulty keeping my checkbook balanced.
I try to get organized, but it never lasts long.
I often pay bills late.
STIMULANTS
____
____
____
I drink four or more cups of coffee or coke per day.
I have used No-Doze or other stimulant pills to keep alert on more than one occasion.
Smoking cigarettes helps me concentrate when I study/do paperwork.
FRUSTRATION TOLERANCE
____
____
____
____
____
I have been called impatient.
I become easily frustrated.
It is hard to tolerate people who do things slowly.
I hate to wait.
I tend to give up quickly if I can’t figure out how to do something.
ANGER
____
____
____
____
I fought frequently as a child.
I have a short fuse.
If someone raises her or his voice at me, I yell back.
I have punched holes in walls or doors out of anger.
____
____
____
I usually become angry if I am criticized.
It is almost impossible for me to remain calm if someone is acting in an angry manner toward me.
I tend to be moody.
EMOTIONAL LABILITY
____
____
____
____
____
____
My feelings (positive or negative) are very intense.
I have “thin skin”.
I have very intense premenstrual symptoms of moodiness or emotionality.
I tend to overreact.
I cry more often than my friends do.
As a child, I was teased for getting upset.
ACADEMICS
____
____
____
____
____
____
____
____
____
____
I have been called an underachiever.
School seemed boring and frustrating for as long as I can remember.
My grades went down in junior high compared to elementary school.
My siblings were better students than I was.
I was diagnosed with learning problems.
My teachers and parents always felt I was unmotivated in school.
My grades varied from A’s to F’s.
My low grades were often resulted in not turning in homework.
Even when I studied hard for tests, during the exam I ‘blanked out” and couldn’t remember
information.
Careless errors have frequently lowered my grades.
ANXIETY/DEMORALIZATION/DEPRESSION
____
____
____
____
____
____
____
____
____
I have had periods when I felt depressed for weeks or months.
I have felt so anxious and overwhelmed that I felt like quitting my job/school.
I worry a lot about my future.
I’m afraid I’ll never “get my act together.”
I have occasionally felt suicidal.
Often I drink or party just to get my mind off my troubles.
I have taken medication for anxiety or depression.
Sometimes I can’t get out of bed because I feel so overwhelmed.
I have headaches, stomachaches, neck aches, or backaches from tension and worry.
SELF-ESTEEM AND CONFIDENCE
____
____
____
____
I tend to put myself down.
I try to avoid competitive situations.
I overreact to criticism.
I can’t take being teased.
____
____
I worry a lot about making mistakes.
I am always “messing up”.
OPPOSITIONAL TENDENCIES
____
____
____
____
____
____
I was a “difficult child”.
I don’t like being told what to do.
I argue a lot.
I have been called stubborn.
I have had many disagreements with my parents, partner, or friends.
I have been fired or have had arguments with supervisors on jobs.
SOCIAL/INTERPERSONAL
____
____
____
____
____
____
____
I was teased a lot as a kid.
I had trouble getting along with other kids.
I always felt “different” as a child.
I have been called bossy.
Sometimes I am too blunt or critical.
Though I don’t mean to be, I have been called inconsiderate.
I tend to have conflicts with roommates or co-workers.
FAMILY HISTORY
____
____
____
____
There is a history of alcoholism in my family.
There is a history of depression in my family.
Other family members (including cousins, aunts, uncles) have been diagnosed as hyperactive or
learning disabled.
One of my parents says he or she was a lot like me when they were younger.
ADHD Diagnostic Criteria Checklist
Name: _______________________________ Student ID#: _______________ Date: ______
Please complete the following questions for behaviors you exhibit now, as an adult, AND
behaviors your remember experiencing as a child. Please check all boxes that apply to you.
Fail to pay close attention to detail or make careless mistakes
Child hood
Y or N
Adult
Y or N
Rush through work
Miss problem/items you knew how to do
Fail to check your work
Have a hard time with detailed school work
Don’t read instructions before starting
Not good at detail work at home (e.g. don’t balance
checkbook
Have difficulty sustaining attention in tasks or play
Childhood
Y or N
Adult
Y or N
Cannot keep mind on single activity for
extended time (e.g. reading, lectures, TV)
Required supervision to stay on task
Long conversations with friends can be
hard to follow
Overall trouble concentrating on paying attention
Trouble remembering what you read and
and need to reread passages over again
Fun activities can be hard to track (e.g., watching a
sporting event, playing a game)
Do not often seem to listen when spoken to directly
Childhood
Y or N
Adult
Y or N
Others (partner, friends, boss) complain
that your mind is “elsewhere” when
spoken to
Parents/teachers had to repeat instruction or raised
their voice in order for you to comply
You were called “spacey” or a
“daydreamer.”
People frequently have to repeat your name to get
your attention.
Eye contact was necessary in order to
hear a conversation
Find it difficult to follow through on instructions
and fail to finish tasks
Childhood
Y or N
Adult
Y or N
Need a deadline to finish tasks
Leave things unfinished
Often jump from project to project
Often completed tasks improperly because you
did not follow instructions
Difficult time following multi-step instructions
Need frequent reminders
Often have difficulty with organization
Poor sense of time
Overscheduled/commit yourself
Home and work environment is messy or
cluttered
Often dislike or avoid tasks that require a lot of sustained
mental effort
Childhood
Y or N
Adult
Y or N
Late for class, appointments, meeting friends
Make “to do” lists, but don’t use them
Hard to prioritize work and chores
Childhood
Y or N
Adult
Y or N
Procrastinate
Often avoid going to class
Delay detailed work like filing taxes
Avoided schoolwork as a child
Feels like a chore to read, listen to lectures, etc.
Avoided reading, puzzles, etc. as a child
Often lose things necessary for tasks or activities
Childhood
Y or N
Adult
Y or N
Frequent lose keys, wallet, cell phone, etc.
Misplace work or school items
Lose to do lists or phone numbers
As a child lost supplies, books, toys, etc.
Easily distracted by extraneous stimuli
Childhood
Y or N
Adult
Y or N
Hard to refocus when interrupted
Train of thought easily sidetracked
Easily distracted by events such as noise
(conversation, radio), movement or clutter
Need to work in relative isolation to get
work done
Hard to get back to a task once you stop
Often forgetful in daily activities
Often forget plans or your schedule
Return home or to the car to get things
you forgot
Childhood
Y or N
Adult
Y or N
Had trouble remembering to do chores
as a child
Often forget instructions before you
completed a task
Need others to help you remember things
Have the above symptoms persisted at least 6 months?
Y or N
At what age did these symptoms first appear?
Age: ____
Did you have any of the above symptoms during childhood (grades K-12)
Where did the symptoms occur?
Home ___
School ___
Y or N
Activities ___
Do you have any of the above symptoms as an adult? Y or N
Where do the symptoms occur?
Home ___
School ___
Activities ___
Work ___
If you have any of the above symptoms, in what areas have they caused impairment/problems?
Home ___
School ___
Activities ___ Work ___
Social ___
Is there anything else you would like to add about questions in this section?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Section II
Fidget with your hands or squirm in your seat
Childhood
Y or N
Adult
Y or N
Difficult to sit still
Squirmy as a child
Tap fingers/hands/feet
Difficulty sitting at your desk
Bite nails or twirl hair
Often left seat in classroom or situation where remaining
seated was expected
Childhood
Y or N
Adult
Y or N
Difficult to stay seated during lecture or
movie
Have trouble staying seated during
meal times, homework, etc.
Would rather be moving than sitting
Moved around classroom without
permission
Often left seat in classroom or situation where remaining
seated was expected
Feel internally restless
Described as “always on the go”
Often have difficulty playing or engaging in activities quietly
Childhood
Y or N
Adult
Y or N
Feel agitated when you cannot exercise
on an almost daily basis
Climbed on things as a child (furniture,
trees, etc.)
Childhood
Y or N
Adult
Y or N
Inappropriate talking during lectures,
movies
Teachers had to remind you to keep quiet
Difficulty controlling volume of your voice
Loud during games
Talking louder than others in restaurants
Always “on the go” or “driven by a motor”
Childhood
Y or N
Adult
Y or N
Always moving
Often try new activities or hobbies
Unable to relax
Endless energy as a child
Others report that you talk excessively
Childhood
Y or N
Adult
Y or N
People complain they “can’t get a word in”
or that you talk too much
Teachers/parents had to remind you to
stop talking
Takes a long time to get to your point across
to others
As a child, you were called a “chatterbox”
or “motor mouth”
Others report you blurt out answers before questions have been
completed
Childhood
Y or N
Adult
Y or N
Often cut off other people’s sentences
Gave first answer that came to mind,
even if it was incorrect
Say things without thinking
Often the first one to respond to
questions as a child
Finish people’s sentences
Often have trouble waiting your turn
Childhood
Y or N
Adult
Y or N
Impatient waiting in lines
Had trouble taking turns (e.g. in sports,
video games, etc.)
Frustrated in traffic
Always needed to be the first in line or
couldn’t stay in line
Avoid situation where you might have to wait
Others report that you often interrupt or intrude on them
Childhood
Y or N
Adult
Y or N
Called intrusive
Become involved in other people’s
business or affairs when you shouldn’t
Can violate others’ personal space/boundaries
Barged into other children’s games
Interrupt conversations or phone calls
Have the above symptoms persisted for at least 6 months?
Y or N
If you reported that you had any of the above symptoms, at what age did these symptoms first appear? Age: ___
If you had any of the above symptoms during childhood years (grades K-12), where did these symptoms occur?
Home ____
School ____
Activities ___
If you had any of the above symptoms as an adult, where have your hyperactive symptoms occurred?
Home ___
School ____
Activities ___
Work ___
If you had any of the above hyperactive symptoms, in what areas have they caused impairment/problems?
Home ___
School ___
Activities ___
Work ___
Social ___
Anything else you would like to add about questions in this section?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Rarely
Sometimes
Often
Very Often
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
8. How often are you distracted by activity or noise around you?
0
1
2
3
4
_____
9. How often do you have problems remembering appointments or obligations?
0
1
2
3
4
_____
Please answer the questions below, rating yourself on each of the criteria shown using the scale on the
right side of the page. As you answer each question, circle the correct number that best describes how
you have felt and conducted yourself over the past 6 months. Please return this completed form no less
than one week before your scheduled appointment.
1. How often do you make careless mistakes when you have to work on a boring or
difficult project?
2. How often do you have difficulty keeping your attention when you are doing
boring or repetitive work?
3. How often do you have difficulty concentrating on what people say to you, even
when they are speaking directly to you?
4. How often do you have trouble wrapping up the final details of a project,
once the challenging parts have been done?
5. How often do you have difficulty getting things in order when you have to do
a task that requires organization?
6. When you have a task that requires a lot of thought, how often do you avoid
or delay getting started?
7. How often do you misplace or have difficulty finding things at home or at work?
PART A --- TOTAL
10. How often do you fidget or squirm with your hands or feet when you have
to sit down for a long time?
11. How often do you leave your seat in meetings or other situations in which
you are expected to remain seated?
12. How often do you feel restless or fidgety?
13. How often do you have difficulty unwinding and relaxing when you have
time to yourself?
14. How often do you feel overly active and compelled to do things, like you
were driven by a motor?
15. How often do you find yourself talking too much when you are in social
situations?
16. When you are in a conversation, how often do you find yourself finishing
the sentences of the people you are talking to, before they can finish
them themselves?
17. How often do you have difficulty waiting your turn in situations when
turn taking is required?
18. How often do you interrupt others when they are busy?
Score
Never
Name: ____________________________________________ Student ID# ______________________ Date: ______________
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
0
1
2
3
4
_____
PART B ---TOTAL
_____
AUDIT Screening
Because alcohol can affect your health and can interfere with certain medications and
treatments, it is important that we ask some questions about your use of alcohol. Your
answers will remain confidential, so please be honest. Please read the questions carefully and
place an X in the one box that best describes your answer to the question.
Please Circle Your Answer
0
1
2
3
4
1. How often do you have a drink containing alcohol?
Never
Monthly
or less
2-4 times
a month
2-3 times
a week
4 or more
times a
week
2. How many drinks containing alcohol do you have on a
typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
3. How often do you have 6 or more drinks on one
occasion ?
Never
Less than
Monthly
Weekly
4. How often during the last year have you found that you
were not able to stop drinking once you had started?
Never
5. How often during the last year have you failed to do
what was normally expected of you because of drinking?
Never
6. How often during the last year have you needed a
first drink in the morning to get yourself going after
a heavy drinking session?
Never
7. How often during the last year have you had a feeling
of guilt or remorse after drinking?
Never
8. How often during the last year have you been unable
to remember what happened the night before because
of your drinking?
Never
9. Have you or someone else been injured because of
drinking?
No
10. Has a relative, friend, doctor, or other health care worker
been concerned about your drinking or suggested you
cut down?
No
monthly
Less than
Monthly
Weekly
monthly
Less than
Daily or
almost
daily
Monthly
Weekly
monthly
Less than
Daily or
almost
daily
Daily or
almost
daily
Monthly
Weekly
monthly
Daily or
almost
daily
Less than
Monthly
Weekly
monthly
Less than
Daily or
almost
daily
Monthly
monthly
Weekly
Daily or
almost
daily
Yes, but
Yes,
not in the
last year
during the
last year
Yes, but
Yes,
not in the
during the
last year
last year
TOTAL
CONTRACT FOR ADHD MANAGEMENT
Stimulants, including medications such as Ritalin and Adderall, are controlled substances (Schedule II
medications) that are used in the treatment of ADHD. The goal is to improve ADHD symptoms with
minimal drug side effects. Compliance with the following guidelines is important to the continuation of
medication management by your psychiatrist.
1. I will provide the psychiatrist with a complete and accurate treatment history, including past
testing records, past medical records, past treatment and any drug addiction history.
2. I will inform the provider of all drug side effects regarding prescribed medication.
3. I will take medications only at the dose and frequency prescribed.
4. I will not increase or change the dose of my medication without the approval of my psychiatrist.
5. I will not request or obtain stimulants from physicians other than from my psychiatrist.
6. I will, where possible, have all prescriptions filled at a single pharmacy.
7. I will protect my prescription and medications. Lost or possibly stolen stimulant medication or
prescriptions may or may not be rewritten at the discretion of the psychiatrist. I will report such
an incident to the WUPD or the University City Police Department.
8. Failure to make appointments within the recommended time frame, keep scheduled
appointments, and /or cancel my appointment a minimum of 24 hours prior to the
appointment may result in inability for my psychiatrist to continue prescribing medication. This
is necessary because the FDA requires close monitoring of these medications and it helps your
psychiatrist to provide you with quality care.
9. If I need a refill before my scheduled appointment, I will call 314-935-6695 and request the
refill. Stimulant medications cannot be refilled early. Most scripts can be picked up in 24 to 48
hours. Prescriptions for stimulant refills cannot be called into a pharmacy. We will call you
when the prescription is ready.
10. I understand that my stimulant treatment may be stopped if any of the following occur:
• The psychiatrist feels that stimulants are not effective for me
• I develop side effects that are significant in the view of the psychiatrist.
• I develop rapid tolerance or loss of effects from this treatment.
• I misuse, share or sell my prescribed medication.
• I alter my prescriptions.
• I take, sell or misuse other drugs.
• I obtain stimulants from sources other than my psychiatrist.
11. I understand that if I have any questions or concerns regarding my treatment, I will call my
psychiatrist.
I have read this form and agree to follow the guidelines as outlined above.
Signed (Patient):______________________________________ Date:__________
Signed (Physician):_____________________________________ Date:__________