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- Headdstrong - New Patient Form
- Headdstrong - Refill Request
-Headdstrong - Medication Follow-Up Form
-Headdstrong - Medication Follow-Up Form
Symptoms
1. Does not pay attention to details or makes careless mistakes with, for example, homework
*
0 Never
1 Occasionally
2 Often
3 Very Often
2. Has difficulty keeping attention to what needs to be done
*
0 Never
1 Occasionally
2 Often
3 Very Often
3. Does not seem to listen when spoken to directly
*
0 Never
1 Occasionally
2 Often
3 Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
*
0 Never
1 Occasionally
2 Often
3 Very Often
5. Has difficulty organizing tasks and activities
*
0 Never
1 Occasionally
2 Often
3 Very Often
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
*
0 Never
1 Occasionally
2 Often
3 Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
*
0 Never
1 Occasionally
2 Often
3 Very Often
8. Is easily distracted by noises or other stimuli
*
0 Never
1 Occasionally
2 Often
3 Very Often
9. Is forgetful in daily activities
*
0 Never
1 Occasionally
2 Often
3 Very Often
10. Fidgets with hands or feet or squirms in seat
*
0 Never
1 Occasionally
2 Often
3 Very Often
11. Leaves seat when remaining seated is expected
*
0 Never
1 Occasionally
2 Often
3 Very Often
12. Runs about or climbs too much when remaining seated is expected
*
0 Never
1 Occasionally
2 Often
3 Very Often
13. Has difficulty playing or beginning quiet play activities
*
0 Never
1 Occasionally
2 Often
3 Very Often
14. Is on the go or often acts as if driven by a motor
*
0 Never
1 Occasionally
2 Often
3 Very Often
15. Talks too much
*
0 Never
1 Occasionally
2 Often
3 Very Often
16. Blurts out answers before questions have been completed
*
0 Never
1 Occasionally
2 Often
3 Very Often
17. Has difficulty waiting his or her turn
*
0 Never
1 Occasionally
2 Often
3 Very Often
18. Interrupts or intrudes in on others? conversations and/or activities
*
0 Never
1 Occasionally
2 Often
3 Very Often
Performance
19. Overall school performance
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
20. Reading
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
21. Writing
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
22. Mathematics
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
23. Relationship with parents
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
24. Relationship with siblings
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
25. Relationship with peers
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
26. Participation in organized activities (eg, teams)
*
1 Excellent
2 Above Average
3 Average
4 Somewhat of a Problem
5 Problematic
Side Effects
27. Headache
*
0 Never
1 Occasionally
2 Often
3 Very Often
28. Stomachache
*
0 Never
1 Occasionally
2 Often
3 Very Often
29. Change of appetite-explain below if necessary
*
0 Never
1 Occasionally
2 Often
3 Very Often
30. Trouble sleeping
*
0 Never
1 Occasionally
2 Often
3 Very Often
31. Irritability in the late morning, late afternoon, or evening- explain below if necessary
*
0 Never
1 Occasionally
2 Often
3 Very Often
32. Socially withdrawn-decreased interaction with others
*
0 Never
1 Occasionally
2 Often
3 Very Often
33. Extreme sadness or unusual crying
*
0 Never
1 Occasionally
2 Often
3 Very Often
34. Dull, tired, listless behavior
*
0 Never
1 Occasionally
2 Often
3 Very Often
35. Tremors/feeling shaky
*
0 Never
1 Occasionally
2 Often
3 Very Often
36. Repetitive movements, tics, jerking, twitching, eye blinking-explain below if necessary
*
0 Never
1 Occasionally
2 Often
3 Very Often
37. Picking at skin or fingers, nail biting, lip or cheek chewing-explain below if necessary
*
0 Never
1 Occasionally
2 Often
3 Very Often
38. Sees or hears things that aren?t there
*
0 Never
1 Occasionally
2 Often
3 Very Often
Comments/Explanations
* Required field
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