Washington University Habif Health and Wellness Center 314-935-6695 ADHD Pre-Appointment Documents The following packet MUST be completed prior to our scheduled appointment. Please fill out the questionnaires and return them at least ONE WEEK before your appointment otherwise your appointment will be cancelled and need to be rescheduled. You will be sent a reminder email. If you have been previously diagnosed with ADHD, you will need a copy of any psychological testing as well as a letter/record from your most recent prescribing physician with documentation of diagnosis, medication, and dose. If you do not have copies of these records, a release of information form will need to be completed so we can access this information. Please note that having a previous diagnosis does not automatically mean you will meet diagnostic criteria currently. Sometimes other mental health concerns (e.g., feeling depressed, using alcohol) can mimic the symptoms of ADHD. If you have received assistance for any mental health concern or substance abuse issue (currently or in the past), we will need a copy of those records (e.g., treatment summary from your counselor/psychiatrist). If you do not have copies of these records, a release of information form will need to be completed so we can access this information. Additional information from someone who knew you well as a child may be needed to determine a diagnosis (e.g., parent, grandparent, teacher). If this is the case, we will need to ask you to complete a release of information for someone who knew you well as a child. If an accurate diagnosis cannot be determined after evaluating your information and meeting with the psychiatrist, further evaluation outside of the Student Health Service may be required. Your doctor will determine whether this is the case. Please call if you have any questions or need assistance with completing this information.
ADULT GENERAL SYMPTOM INVENTORY Instructions: Rate each statement by placing the appropriate number corresponding to how you feel about the statement in the space to the left of each item. If an item does not apply to you, write NA for not applicable. 0- This statement does not describe me at all. 1- This statement describes me to a slight degree. 2- The statement describes me to a moderate degree. 3- The statement describes me to a large degree. 4- The statement describes me to a very large degree. NA Not Applicable IMPULSIVITY/SELF-CONTROL I tend to go with my feelings and often don t think before I act. I interrupt others in conversation. Sometimes I hurt people s feelings without meaning to because I speak before I think. I got in trouble in school for talking or misbehaving. I am a risk taker. I make decisions quickly. When I have a job to do, I just dive in and figure it out as I go. I have had more than my share of speeding tickets or car accidents. HYPERFOCUSING Sometimes I become so involved in what I m doing that I completely lose track of time. When people talk to me or call me when I m engrossed in something, I frequently don t hear the them. TIME MANAGEMENT I have trouble being on time. I tend to procrastinate. I am unrealistic about how long a task will take. I tend to make too many commitments. I am often late for appointments or meetings. No matter how good my intentions are, I end up (or used to end up) doing all-nighters before exams. SELF-DISCIPLINE I have difficulty sticking to my plans for self-improvement. I can t tear myself away from activities I like, even when I know I will be late for something. I usually do what I like, and put off things that I ought to do. The only way I can get myself to do boring projects or tasks is to wait until the deadline. I have started and dropped many interests.
I have been called lazy. I have been called irresponsible. SLEEP/AROUSAL PROBLEMS I have very irregular sleep patterns. Falling asleep at night has always been difficult for me. I am a restless sleeper. It is hard for me to wake up in the morning. I often oversleep. When sitting in class or studying, I quickly feel tired, mo matter how much sleep I got the night before. I tend to fall asleep for catnaps if I sit down or lie down to relax. ORGANIZATION/STRUCTURE I rarely plan my day. I tend to be messy. Other people have complained about my disorganization or messiness. I have trouble keeping up with several simultaneous projects. I have become overwhelmed when I have too many choices. I have trouble managing money. I have difficulty keeping my checkbook balanced. I try to get organized, but it never lasts long. I often pay bills late. STIMULANTS I drink four or more cups of coffee or coke per day. I have used No-Doze or other stimulant pills to keep alert on more than one occasion. Smoking cigarettes helps me concentrate when I study/do paperwork. FRUSTRATION TOLERANCE I have been called impatient. I become easily frustrated. It is hard to tolerate people who do things slowly. I hate to wait. I tend to give up quickly if I can t figure out how to do something. ANGER I fought frequently as a child. I have a short fuse. If someone raises her or his voice at me, I yell back. I have punched holes in walls or doors out of anger.
I usually become angry if I am criticized. It is almost impossible for me to remain calm if someone is acting in an angry manner toward me. I tend to be moody. EMOTIONAL LABILITY My feelings (positive or negative) are very intense. I have thin skin. I have very intense premenstrual symptoms of moodiness or emotionality. I tend to overreact. I cry more often than my friends do. As a child, I was teased for getting upset. ACADEMICS I have been called an underachiever. School seemed boring and frustrating for as long as I can remember. My grades went down in junior high compared to elementary school. My siblings were better students than I was. I was diagnosed with learning problems. My teachers and parents always felt I was unmotivated in school. My grades varied from A s to F s. My low grades were often resulted in not turning in homework. Even when I studied hard for tests, during the exam I blanked out and couldn t remember information. Careless errors have frequently lowered my grades. ANXIETY/DEMORALIZATION/DEPRESSION I have had periods when I felt depressed for weeks or months. I have felt so anxious and overwhelmed that I felt like quitting my job/school. I worry a lot about my future. I m afraid I ll never get my act together. I have occasionally felt suicidal. Often I drink or party just to get my mind off my troubles. I have taken medication for anxiety or depression. Sometimes I can t get out of bed because I feel so overwhelmed. I have headaches, stomachaches, neck aches, or backaches from tension and worry. SELF-ESTEEM AND CONFIDENCE I tend to put myself down. I try to avoid competitive situations. I overreact to criticism. I can t take being teased.
I worry a lot about making mistakes. I am always messing up. OPPOSITIONAL TENDENCIES I was a difficult child. I don t like being told what to do. I argue a lot. I have been called stubborn. I have had many disagreements with my parents, partner, or friends. I have been fired or have had arguments with supervisors on jobs. SOCIAL/INTERPERSONAL I was teased a lot as a kid. I had trouble getting along with other kids. I always felt different as a child. I have been called bossy. Sometimes I am too blunt or critical. Though I don t mean to be, I have been called inconsiderate. I tend to have conflicts with roommates or co-workers. FAMILY HISTORY There is a history of alcoholism in my family. There is a history of depression in my family. Other family members (including cousins, aunts, uncles) have been diagnosed as hyperactive or learning disabled. One of my parents says he or she was a lot like me when they were younger.
ADHD Diagnostic Criteria Checklist Name: Student ID#: Date: Please complete the following questions for behaviors you exhibit now, as an adult, AND behaviors your remember experiencing as a child. Please check all boxes that apply to you. Fail to pay close attention to detail or make careless mistakes Child hood Adult Rush through work Fail to check your work Don t read instructions before starting Miss problem/items you knew how to do Have a hard time with detailed school work Not good at detail work at home (e.g. don t balance checkbook Have difficulty sustaining attention in tasks or play Childhood Adult Cannot keep mind on single activity for extended time (e.g. reading, lectures, TV) Long conversations with friends can be hard to follow Trouble remembering what you read and and need to reread passages over again Required supervision to stay on task Overall trouble concentrating on paying attention Fun activities can be hard to track (e.g., watching a sporting event, playing a game) Do not often seem to listen when spoken to directly Childhood Adult Others (partner, friends, boss) complain that your mind is elsewhere when spoken to You were called spacey or a daydreamer. Parents/teachers had to repeat instruction or raised their voice in order for you to comply People frequently have to repeat your name to get your attention. Eye contact was necessary in order to hear a conversation
Find it difficult to follow through on instructions Childhood Adult and fail to finish tasks Need a deadline to finish tasks Often jump from project to project Difficult time following multi-step instructions Leave things unfinished Often completed tasks improperly because you did not follow instructions Need frequent reminders Often have difficulty with organization Childhood Adult Poor sense of time Overscheduled/commit yourself Home and work environment is messy or cluttered Late for class, appointments, meeting friends Make to do lists, but don t use them Hard to prioritize work and chores Often dislike or avoid tasks that require a lot of sustained Childhood Adult mental effort Procrastinate Delay detailed work like filing taxes Often avoid going to class Avoided schoolwork as a child Feels like a chore to read, listen to lectures, etc. Avoided reading, puzzles, etc. as a child Often lose things necessary for tasks or activities Childhood Adult Frequent lose keys, wallet, cell phone, etc. Lose to do lists or phone numbers Misplace work or school items As a child lost supplies, books, toys, etc.
Easily distracted by extraneous stimuli Childhood Adult Hard to refocus when interrupted Easily distracted by events such as noise (conversation, radio), movement or clutter Train of thought easily sidetracked Need to work in relative isolation to get work done Hard to get back to a task once you stop Often forgetful in daily activities Childhood Adult Often forget plans or your schedule Return home or to the car to get things you forgot Had trouble remembering to do chores as a child Often forget instructions before you completed a task Need others to help you remember things Have the above symptoms persisted at least 6 months? At what age did these symptoms first appear? Y or N Age: Did you have any of the above symptoms during childhood (grades K-12) Y or N Where did the symptoms occur? Home School Activities Do you have any of the above symptoms as an adult? Y or N Where do the symptoms occur? Home School Activities Work If you have any of the above symptoms, in what areas have they caused impairment/problems? Home School Activities Work Social Is there anything else you would like to add about questions in this section?
Section II Fidget with your hands or squirm in your seat Childhood Adult Difficult to sit still Tap fingers/hands/feet Squirmy as a child Difficulty sitting at your desk Bite nails or twirl hair Often left seat in classroom or situation where remaining Childhood Adult seated was expected Difficult to stay seated during lecture or movie Would rather be moving than sitting Have trouble staying seated during meal times, homework, etc. Moved around classroom without permission Often left seat in classroom or situation where remaining Childhood Adult seated was expected Feel internally restless Described as always on the go Feel agitated when you cannot exercise on an almost daily basis Climbed on things as a child (furniture, trees, etc.) Often have difficulty playing or engaging in activities quietly Childhood Adult Inappropriate talking during lectures, movies Difficulty controlling volume of your voice Teachers had to remind you to keep quiet Loud during games Talking louder than others in restaurants
Always on the go or driven by a motor Childhood Adult Always moving Unable to relax Often try new activities or hobbies Endless energy as a child Others report that you talk excessively Childhood Adult People complain they can t get a word in or that you talk too much Takes a long time to get to your point across to others Teachers/parents had to remind you to stop talking As a child, you were called a chatterbox or motor mouth Others report you blurt out answers before questions have been Childhood Adult completed Often cut off other people s sentences Say things without thinking Gave first answer that came to mind, even if it was incorrect Often the first one to respond to questions as a child Finish people s sentences Often have trouble waiting your turn Childhood Adult Impatient waiting in lines Frustrated in traffic Had trouble taking turns (e.g. in sports, video games, etc.) Always needed to be the first in line or couldn t stay in line Avoid situation where you might have to wait
Others report that you often interrupt or intrude on them Childhood Adult Called intrusive Can violate others personal space/boundaries Become involved in other people s business or affairs when you shouldn t Barged into other children s games Interrupt conversations or phone calls Have the above symptoms persisted for at least 6 months? Y or N If you reported that you had any of the above symptoms, at what age did these symptoms first appear? Age: If you had any of the above symptoms during childhood years (grades K-12), where did these symptoms occur? Home School Activities If you had any of the above symptoms as an adult, where have your hyperactive symptoms occurred? Home School Activities Work If you had any of the above hyperactive symptoms, in what areas have they caused impairment/problems? Home School Activities Work Social Anything else you would like to add about questions in this section?
Name: Student ID# Date: Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, circle the correct number that best describes how you have felt and conducted yourself over the past 6 months. Please return this completed form no less than one week before your scheduled appointment. Never Rarely Sometimes Often Very Often Score 1. How often do you make careless mistakes when you have to work on a boring or 0 1 2 3 4 difficult project? 2. How often do you have difficulty keeping your attention when you are doing 0 1 2 3 4 boring or repetitive work? 3. How often do you have difficulty concentrating on what people say to you, even 0 1 2 3 4 when they are speaking directly to you? 4. How often do you have trouble wrapping up the final details of a project, 0 1 2 3 4 once the challenging parts have been done? 5. How often do you have difficulty getting things in order when you have to do 0 1 2 3 4 a task that requires organization? 6. When you have a task that requires a lot of thought, how often do you avoid 0 1 2 3 4 or delay getting started? 7. How often do you misplace or have difficulty finding things at home or at work? 0 1 2 3 4 8. How often are you distracted by activity or noise around you? 0 1 2 3 4 9. How often do you have problems remembering appointments or obligations? 0 1 2 3 4 PART A --- TOTAL 10. How often do you fidget or squirm with your hands or feet when you have 0 1 2 3 4 to sit down for a long time? 11. How often do you leave your seat in meetings or other situations in which 0 1 2 3 4 you are expected to remain seated? 12. How often do you feel restless or fidgety? 0 1 2 3 4 13. How often do you have difficulty unwinding and relaxing when you have 0 1 2 3 4 time to yourself? 14. How often do you feel overly active and compelled to do things, like you 0 1 2 3 4 were driven by a motor? 15. How often do you find yourself talking too much when you are in social 0 1 2 3 4 situations? 16. When you are in a conversation, how often do you find yourself finishing 0 1 2 3 4 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 0 1 2 3 4 turn taking is required? 18. How often do you interrupt others when they are busy? 0 1 2 3 4 PART B ---TOTAL
AUDIT Screening Because alcohol can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest. Please read the questions carefully and place an X in the one box that best describes your answer to the question. Please Circle Your Answer 0 1 2 3 4 1. How often do you have a drink containing alcohol? Never Monthly 2-4 times 2-3 times 4 or more or less a month a week times a week 2. How many drinks containing alcohol do you have on a 1 or 2 3 or 4 5 or 6 7 to 9 10 or more typical day when you are drinking? 3. How often do you have 6 or more drinks on one Never Less than Monthly Weekly Daily or occasion? monthly almost daily 4. How often during the last year have you found that you Never Less than Monthly Weekly Daily or were not able to stop drinking once you had started? monthly almost daily 5. How often during the last year have you failed to do Never Less than Monthly Weekly Daily or what was normally expected of you because of drinking? monthly almost daily 6. How often during the last year have you needed a Never Less than Monthly Weekly Daily or first drink in the morning to get yourself going after monthly almost a heavy drinking session? daily 7. How often during the last year have you had a feeling Never Less than Monthly Weekly Daily or of guilt or remorse after drinking? monthly almost daily 8. How often during the last year have you been unable Never Less than Monthly Weekly Daily or to remember what happened the night before because monthly almost of your drinking? daily 9. Have you or someone else been injured because of No Yes, but Yes, drinking? not in the during the last year last year 10. Has a relative, friend, doctor, or other health care worker No Yes, but Yes, been concerned about your drinking or suggested you not in the during the cut down? last year last year TOTAL
CONTRACT FOR ADHD MANAGEMENT Stimulants, including medications such as Ritalin and Adderall, are controlled substances (Schedule II medications) that are used in the treatment of ADHD. The goal is to improve ADHD symptoms with minimal drug side effects. Compliance with the following guidelines is important to the continuation of medication management by your psychiatrist. 1. I will provide the psychiatrist with a complete and accurate treatment history, including past testing records, past medical records, past treatment and any drug addiction history. 2. I will inform the provider of all drug side effects regarding prescribed medication. 3. I will take medications only at the dose and frequency prescribed. 4. I will not increase or change the dose of my medication without the approval of my psychiatrist. 5. I will not request or obtain stimulants from physicians other than from my psychiatrist. 6. I will, where possible, have all prescriptions filled at a single pharmacy. 7. I will protect my prescription and medications. Lost or possibly stolen stimulant medication or prescriptions may or may not be rewritten at the discretion of the psychiatrist. I will report such an incident to the WUPD or the University City Police Department. 8. Failure to make appointments within the recommended time frame, keep scheduled appointments, and /or cancel my appointment a minimum of 24 hours prior to the appointment may result in inability for my psychiatrist to continue prescribing medication. This is necessary because the FDA requires close monitoring of these medications and it helps your psychiatrist to provide you with quality care. 9. If I need a refill before my scheduled appointment, I will call 314-935-6695 and request the refill. Stimulant medications cannot be refilled early. Most scripts can be picked up in 24 to 48 hours. Prescriptions for stimulant refills cannot be called into a pharmacy. We will call you when the prescription is ready. 10. I understand that my stimulant treatment may be stopped if any of the following occur: The psychiatrist feels that stimulants are not effective for me I develop side effects that are significant in the view of the psychiatrist. I develop rapid tolerance or loss of effects from this treatment. I misuse, share or sell my prescribed medication. I alter my prescriptions. I take, sell or misuse other drugs. I obtain stimulants from sources other than my psychiatrist. 11. I understand that if I have any questions or concerns regarding my treatment, I will call my psychiatrist. I have read this form and agree to follow the guidelines as outlined above. Signed (Patient): Date: Signed (Physician): Date: