ADHD Evaluation Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Todays Date: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Check any statement that sounds like your child: Attentive presentation: *Fails to give close attention to details or makes careless mistakes.Has difficulty sustaining attention.Does not appear to listen.Struggles to follow through on instructions.Has difficulty with organization.Avoids or dislikes tasks requiring a lot of thinking.Loses things.Is easily distracted.Is forgetful in daily activities.N/AHyperactive-impulsive presentation: *Fidgets with hands or feet or squirms in chair.Has difficulty remaining seated.Runs about or climbs excessively in children; extreme restlessness in adults.Difficulty engaging in activities quietly.Acts as if driven by a motor; adults will often feel inside like they were driven by a motor.Talks excessively.Blurts out answers before questions have been completed.Difficulty waiting or taking turns.Interrupts or intrudes upon others.N/AThe section below is to only be completed by the physician: Physician Name: Joseph E WhitfieldPeggy Jo KoepselCombined inattentive & hyperactive-impulsive presentation:They have symptoms from both of the above presentations.I have reviewed the above symptoms per the DMS5 and have determined that this patient meets the requirements for ADHD.Submit
