ADHD Screening Checklist for Families Date MM DD YYYY Name * First Name Last Name Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Best Phone (###) ### #### Second Phone (###) ### #### Email * Date of Birth * MM DD YYYY Gender * Male Female Transgender Non-binary/non-conforming Prefer not to respond Marital Status * Person or party responsible for payment of patient account * Patient/Guarantor Information: (complete only if someone other than the patient is financially responsible) Address of responsible party * ADHD SCREENING CHECKLIST FOR FAMILY This form is to be completed by a parent, sibling or spouse. DO NOT leave blank. This checklist inquiries about lifelong behaviors. Answer "Yes" only if your family member has had the particular trait consistently as long as you can remember. If you do not know or don’t remember, enter a question mark (?). Name of Patient * First Name Last Name Your Relation to Patient * For their entire life has your family member consistently had trouble paying attention to details or made careless errors in their work? * Yes No Have they had a lifelong difficulty concentrating on tasks which they find boring or uninteresting? * Yes No Do they often daydream or not seem to listen when people speak to them directly? * Yes No For their entire life have they consistently had difficulty finishing projects they’ve started? (Do they have a lot of half-finished projects around the home or office?) * Yes No Do they have difficulty organizing their work or become disorganized if not strictly following a plan or list? * Yes No Do they procrastinate or put off undesirable tasks until the last possible moment? * Yes No Have they always had a tendency to lose things necessary to accomplish their daily activities (For example, do they spend time almost every day searching for keys, tools, checkbook, etc.?) * Yes No Have they always been easily distracted by unimportant sounds and events around them? * Yes No Have they always been forgetful (ex: forget names, assignments, etc.)? * Yes No Have they always had difficulty sitting still or fidgeted excessively (even though they can now consciously control it)? * Yes No For as long as you can remember, have they been restless (e.g. unconsciously patted their feet, not been able to get comfortable sitting in a chair or lying in bed)? * Yes No For their entire life have they had significant difficulty relaxing or slowing down enough to do leisure activities quietly? * Yes No Would they always be described as “high energy” or “always on the go”? * Yes No Have they always talked excessively and/or often lost track of what they’re saying in conversations? * Yes No For their entire life have they had a pattern of blurting out the answer before the questions have been completed? * Yes No Have they always been impatient or had difficulty waiting their turn in group situations? (e.g., waiting in line at the grocery store or driving in traffic)? * Yes No Do they frequently interrupt or intrude on others (e.g.. butt into conversations, games, etc.)? * Yes No Have they always been very sensitive (significantly more sensitive than other people you know) to rejection, teasing, criticism, and frustration? * Yes No Do they have a hot temper for which they have no warning? * Yes No Do they have stand-up comedy tendencies or a “wacky/zany” sense of humor? * Yes No Do they have a habit of falling asleep when they sit still or suddenly get drowsy when boring tasks are prolonged? * Yes No For as long as you can remember have they had a great deal of difficulty waking up and being fully alert in the morning? * Yes No Do they have a tendency to move about excessively during sleep? * Yes No For their entire life have they consistently had trouble "turning off their mind" so they could fall asleep? * Yes No Do they "Hyperfocus"? * That is, do they have periods of activity during which they are so engrossed or involved in what they are doing that they are un-distractible by people or events around them and lose track of the passage of time? Yes No If yes, in what sort of activities do you Hyperfocus? Reading Computer/Internet Gardening Artistic Activities Games/Sports Other CONSENT AND DISCLOSURE I understand and agree that all communication between my physician and me is held in confidence unless: 1. I authorize release of information with my signature. 2. My physician is ordered by a court to release information. 3. Child or elder abuse is reasonably suspected. 4. My physician believes that there is imminent risk of my harming an identifiable third party or myself. I understand that in the latter three cases the physician is required by law to inform legal authorities and/or potential victims. Initials * Date * MM DD YYYY Privacy Policy Because we take the protection of your protected health information (PHI) very seriously, we take every reasonable measure to protect it: 1. Your office visits are private and all notes taken are kept in locked storage. 2. All electronic prescribing systems are password protected and encrypted. 3. All emails are sent only to the address you designate and apart from your email address, only contain the PHI you choose to share. I will never ask for PHI, including medication information. Your information will never be sold and will only be shared with your permission. Initials * Date MM DD YYYY FINANCIAL POLICY I UNDERSTAND AND AGREE THAT FULL PAYMENT IS DUE AT THE TIME OF SERVICE and that this practice does not carry balances for any patient. Acceptable forms of payment are cash, check or credit card. • Responsibility for payment for services to a dependent child rests with the custodial parent who seeks treatment. • I understand and accept that Brendon Pardington PA-C is not a member of any managed care panel. As a courtesy to patients Brendon Pardington PA-C will provide billing statements and completed claim forms based on information that I have provided. I understand, however, that it is my responsibility to verify coverage and to obtain all necessary preauthorization of services required by my insurance carrier. I understand and accept that I am personally responsible for payment of the entire bill at the time of service regardless of the decisions of my insurance company. Initials * Date * MM DD YYYY I understand and accept that Brendon's hourly rate is $200 per hour: The Initial Intake Appointment usually takes between 90 minutes to 2 hours. • Costs between $300 - $400. The 30-minute follow-up Med Check Appointments (avg of every 3 months): • Cost $100 per 30 minutes. Initials * Date * MM DD YYYY I understand and accept that Brendon Pardington PA-C has set aside time especially for my care and, therefore, I will pay for all missed appointments and appointments not canceled with 24 hour notice. I understand that my insurance carrier will not be billed for missed or canceled appointments and that they will be my sole financial responsibility. Signature * Date * MM DD YYYY Thank you!
