Village Family Clinic & Wellness Center

Name: * Date * What prescription(s) do you need refilled today? What pharmacy do you use? (Please include name and location of pharmacy) * 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? * 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? * 3. How often do you have problems remembering appointments or obligations? * 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? * 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? * 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? * 7. How often do you make careless mistakes when you have to work on a boring or difficult project? * 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? * 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? * 10. How often do you misplace or have difficulty finding things at home or at work? * 11. How often are you distracted by activity or noise around you? * 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? * 13. How often do you feel restless or fidgety? * 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? * 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? * How is your appetite? * How often are you exercising? * How is your sleep quality? * Are you experiencing any challenges at home, work or school since your last visit? If so, please provide a brief summary. * Have you experienced any positive changes at home, work or school since your last visit? If so, please provide a brief summary. * Do you have any concerns about treatment? *

Thank you! Please press "submit" when you are finished.