Healthcare ADHD Assessment Form

Healthcare ADHD Assessment Form

Patient Information

Patient Name:

Date of Birth:   Gender:

Emergency & Referral

Presenting Concerns & History

Symptom Checklist — Children/Adolescents & Adults

Instructions: For each behavior below, indicate whether it is currently present and, if known, approximate age when it began. Check Current if observed during the past 6 months.

Inattention

Hyperactivity / Impulsivity

Functional Impact and Developmental History

Symptoms are observed in (check all that apply):

Home    School / Work    Social / Peer Relationships    Driving / Safety

Approximate age when symptoms were first noticed:

Collateral Information & Prior Assessments

Collateral sources available (check all that apply): Parent / Guardian    Teacher    Employer    Prior Records

Substance Use, Sleep, and Medical Factors

Alcohol use:   Tobacco / Nicotine:

Clinical Determinations & Administrative Notices

Clinician will evaluate information provided, collateral reports, and testing data to determine whether diagnostic criteria for Attention-Deficit/Hyperactivity Disorder are met and whether symptoms cause clinically significant impairment across settings. This assessment is not a stand-alone determination for medication management without clinical interview and, if required, standardized measures.

Limits to confidentiality: Information disclosed during the assessment will be kept confidential except as required or permitted by law, including mandatory reporting of suspected child, elder, or dependent adult abuse, imminent risk of harm to self or others, and as authorized in writing by the patient or legal guardian.

I authorize the assessor to obtain and release relevant medical, educational, and mental health information as needed to complete this evaluation and to coordinate care with other treating providers.

By signing below I attest that the information I have provided is true and complete to the best of my knowledge. I understand that withholding relevant medical or psychiatric history may affect diagnostic impressions and treatment recommendations. I consent to the clinical assessment described above.

Acknowledgment and Consent

I understand that the assessment may include clinical interview, symptom rating scales, review of records, and, where indicated, standardized testing. I consent to the collection of information necessary to complete the evaluation and to communication between providers for purposes of diagnosis and treatment planning.

I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization. This authorization will expire on the date provided above, if any, or otherwise as required by applicable law.

Consent for electronic or verbal communication regarding appointment coordination and assessment scheduling: I consent

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