Appointment Check In
Thank you for taking the time time give us this important information.
Today's date
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Name
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First
Last
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Name
Preferred Pronouns
She/Her
He/Him
They/Them
Person(s) accompanying patient for the appointment:
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If more than one parent/guardian is present, list all names
Relationship to patient:
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Mother
Father
Self
Other
What is your preferred pharmacy?
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Name and cross streets or phone number
Please lets us know if there have been any changes to the following:
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Phone number or email address
Preferred Pharmacy
Insurance
Address
Medications
Drug Allergies
No Changes
Please list changes here:
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Is this a telehealth/virtual appointment?
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Yes
No
Current height
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Current weight
*
What is the most important thing that you would like addressed at your appointment?
*
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Please mark if you’ve had any of the following in the past one month
Neurological
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None
Motor tics
Vocal tics
Seizures
Abnormal movements
Tremor
Numbness/tingling
Muscle weakness
Headaches
Psychiatric
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None
Persistent sad mood
Irritability
Violent behavior
Anger outbursts
Thoughts about dying
Self harm
Thoughts of harming others
Destruction of property
Odd behavior
Seeing things
Hearing things
Paranoia
Excessive worry
Poor focus
Inability to sit still/fidgeting
Hyperactivity
Problems with peers
Academic failure
School avoidance
Poor sleep
Please list any additional physical concerns not mentioned above
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Behavior Rating Scales
Is the patient 18 years or older?
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Yes
No
Are you currently being treated/taking medication for any of the following:
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Anxiety
Depression
ADHD
None of the above
Do you have NEW concerns for any of the following: (do not select if already chosen above)
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Anxiety
Depression
ADHD
None of the above
Is your child currently being treated/taking medication for any of the following:
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ADHD
Anxiety
Depression
None of the above
Do you have NEW concerns (not previously diagnosed) for any of the following conditions? (do not select if already chosen above)
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ADHD
Anxiety
Depression
None of the above
Submit
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Patient Health Questionnaire- 9 (PHQ-9)
PHQ-9 - Depression Over the last 2 weeks, how often have you been bothered by any of the following problems?
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Rows
Not at all
Several Days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or over eating
Feeling bad about yourself- or that you're a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching TV/videos
Moving or speaking so slowly that other people could have noticed- or being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or hurting yourself in some way
If you checked any of the problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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Rows
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Difficulty
Score
If this page is blank, go to the next page
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GAD- 7 Anxiety
GAD-7 - Anxiety Over the last 2 weeks, how often have you been bothered by the following problems?
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Rows
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen
If you checked any of the problems above, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
*
Rows
Not at all
Somewhat difficult
Very difficult
Extremely difficult
Difficulty
Score
If this page is blank, go to the next page
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NICHQ Vanderbilt Assessment Follow-up-- Parent Informant
Each rating should be considered in the context of what is appropriate for the age of your child. Please think about your child's behaviors since the last assessment scale was filled out when rating their behaviors.
This evaluation is based on a time when the child:
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Was on medication
Was not on medication
Not sure
Symptoms
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Rows
Never
Occasionally
Often
Very often
Does not pay attention to details or makes careless mistakes with, for example, homework or chores
Has difficulty keeping attention to what needs to be done
Does not seem to listen when spoken to directly
Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
Has difficulty organizing tasks or activities
Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
Is easily distracted by noises or other stimuli
Forgetful in daily activities
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Fidgets with hands or feet or squirms in their seat
Leaves seat when remaining seated is expected
Runs about or climbs too much when remaining seated is expected
Has difficulty playing or beginning quiet play activities
Is "on the go" or acts as if "driven by a motor"
Talks excessively
Blurts out answers before questions are completed
Has difficulty waiting their turn
Interrupts or intrudes in on others' conversations and/or activities
Inattentive Symptoms
Hyper/Impulsive Symptoms
Performance
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Rows
Excellent
Above average
Average
Somewhat of a problem
Problematic
Overall school performance
Reading
Writing
Mathematics
Relationship with parents
Relationship with siblings
Participation in organized activities (i.e. teams/sports)
Has your child experienced any of the following side effects or problems in the past week?
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Rows
None
Mild
Moderate
Severe
Headache
Stomachache
Change of appetite (explain below)
Trouble sleeping
Irritability in the late morning, late afternoon, or evening (explain below)
Socially withdrawn- decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/ feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking (explain below)
Picking at skin or fingers, nail biting, lip or cheek chewing (explain below)
Sees or hears things that are not there
Explain any choices above:
If this page is blank, go to the next page
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NICHQ Vanderbilt Initial Assessment Scale- Parent Informant
Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child's behaviors in the last 6 months.
Is this evaluation based on a time when the child:
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Was on medication
Was not on medication
Not sure
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Does not pay attention to details or makes careless mistakes with, for example, homework or chores
Has difficulty keeping attention to what needs to be done
Does not seem to listen when spoken to directly
Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
Has difficulty organizing tasks or activities
Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
Is easily distracted by noises or other stimuli
Forgetful in daily activities
Score
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Fidgets with hands or feet or squirms in seat
Leaves seat when remaining seated is expected
Runs about or climbs too much when remaining seated is expected
Has difficulty playing or beginning quiet play activities
Is "on the go" or acts as if driven by a motor
Talks too much
Blurts out answers before questions have been completed
Has difficulty waiting their turn
Interrupts or intrudes on others' conversations and/or activities
Score
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Argues with adults
Loses temper
Actively defies or refuses to go along with adults' requests or rules
Deliberately annoys people
Blames others for their own mistakes/misbehaviors
Is touchy or easily annoyed by others
Is angry or resentful
Is spiteful and wants to get even
Score
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Bullies, threatens, or intimidates others
Starts physical fights
Lies to get out of trouble or to avoid problems (ie, "cons" others)
Is truant from school (skips school) without permission
Is physically cruel to people
Has stolen things that have value
Deliberately destroys others' property
Has used a weapon that can cause serious harm (bat, knife, brick, gun)
Is physically cruel to animals
Has deliberately set fires to cause damage
Has broken into someone else's home, business, or car
Has stayed out at night without permission
Has run away from home overnight
Has forced someone into sexual activity
Score
Symptoms
*
Rows
Never
Occasionally
Often
Very often
Is fearful, anxious, or worried
Is afraid to try new things for fear of making mistakes
Feels worthless or inferior
Blames self for problems, feels guilty
Feels lonely, unwanted, or unloved; complains that "no one loves me"
Is sad, unhappy, or depressed
Is self-conscious or easily embarrassed
Score
Performance
*
Rows
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
Overall school performance
Reading
Writing
Mathematics
Relationship with parents
Relationship with siblings
Relationship with peers
Participation in organized activities (i.e. sports/team)
If this page is blank, go to the next page
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Adult ADHD Screening
ASRS-V1.1
Please answer the questions below, rating yourself on each of the criteria shown using the scale. Select the rating that best describes how you have felt and conducted yourself over the past SIX months.
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Rows
Never
Rarely
Sometimes
Often
Very Often
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?
Part B
Rows
Never
Rarely
Sometimes
Often
Very Often
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’re 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?
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