Jump to Content
Village Family Clinic & Wellness Center
Home
Forms
Make a Payment
Available Forms
#2 NEW PATIENT- ADHD assessment
*Binge eating disorder assessment
*FOLLOW-UP FORM: Anxiety
*FOLLOW-UP FORM: Depression
MDQ follow-up
Medication renewal form
*FOLLOW-UP FORM: ADHD
Patient survey
*FOLLOW-UP FORM: ADHD
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?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
3. How often do you have problems remembering appointments or obligations?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
10. How often do you misplace or have difficulty finding things at home or at work?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
11. How often are you distracted by activity or noise around you?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
13. How often do you feel restless or fidgety?
*
0 - Never
1 - Rarely
2 - Sometimes
3 - Often
4 - Very often
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
15. How often do you find yourself talking too much when you are in social situations?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
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?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
18. How often do you interrupt others when they are busy?
*
0 - Never
1 - Rarely
2- Sometimes
3 - Often
4 - Very often
How is your appetite?
*
Lousy
Fair
Good
How often are you exercising?
*
Never
1-2 days
2-3 days a week
4 or more days a week
How is your sleep quality?
*
1
2
3
4
5
6
7
8
9
10
1=POOR 10=GREAT
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.
* Required field
Submit Form