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. 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 Dosage Time taken? Is your medication taken daily (including weekends/holidays)? * Yes No If no, how often? 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feeling * None Mild Moderate Severe Explain Dull, tired, listless * None Mild Moderate Severe Explain Socially withdrawn * None Mild Moderate Severe Explain Hallucinations * None Mild Moderate Severe Explain Repetitive Movements (tics, twitching) * None Mild Moderate Severe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 If you are human, leave this field blank. Submit
