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ADHD Neuropsychology Extra Intake Information
ADHD Neuropsych Extra Intake Information - Practitioner Use
ADHD Neuropsych Extra Intake Information - Practitioner Use
ADHD Neuropsych Extra Intake Information - Practitioner Use
Client Name
*
Client Name
First
First
Last
Last
Date of Birth
*
Diagnosis
Notes
*
Reason for Referral
Notes
*
Developmental History
Pregnancy and/or Birth Complications
*
Born at __ weeks gestation
*
Temperament as a baby/infant?
*
Any developmental delays?
*
Hyperactivity Symptoms
Check when client was younger and current concerns with the following (Needs to meet at least 6 symptoms)
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, and other activities?
*
Often has difficulty sustaining attention in tasks and play activities?
*
Often does not seem to listen when spoken to directly?
*
Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (but not due to oppositional behaviour and not because of a failure to understand)?
*
Often has difficulty organising tasks and activities?
*
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)?
*
Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)?
*
Often easily distracted by extraneous stimuli?
*
Often forgetful in daily activities?
*
Inattentive Symptoms
Check when client was younger and current concerns with the following (Needs to meet at least 6 symptoms)
Often fidgets with hands or feet or squirms in seat?
*
Often leaves seat in classroom or in other situations in which remaining seated is expected?
*
Often runs about or climbs excessively in situations in which remaining seated is expected (in adolescents and adults, may be limited to feelings of restlessness)?
*
Often has difficulty playing or engaging in leisure activities quietly?
*
Often "on the go" or acts as if "driven by a motor"?
*
Often talks excessively?
*
Impulsivity
Often blurts out answers before questions have been completed?
*
Often has difficulty awaiting turn?
*
Often interrupts or intrudes on others (e.g. butts into conversations or games)?
*
Medical History / Medications
Any past or current medical diagnosis?
*
Check TBI, seizures, dementia, sleep disturbance
*
Current Medications
*
Substance Use History
Check drugs, caffeine, alcohol
*
Sensory Deficits and Hypersensitivities
Does the client have sensory hypersensitivities?
*
Significant Trauma History
Notes
*
Educational History / Learning Difficulties
Rule out ID/Learning Disability
*
Learning approach: Hands on/off
*
Other Mental Health Conditions
Mood Disorders (Bipolar, MDD)
*
Anxiety Disorders (PTSD, OCD)
*
ODD/Conduct Disorder
*
Family History
Notes
*
Current Supports
Notes
*
Current Hobbies / Interests
Notes
*
Assessment Completed By
Name
*
Position
*
Assessment Date
*
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