Medication Management - Questionnaire's

⭕ Patient (18 or older)⭕ Legal Guardian completing on behalf of a minor

Client Name: {clientName}

Date: {date41}

Instructions to Parent or Guardian: Questions P1-P19 ask about the early development and early and current home experiences of your child. Some questions require that you think as far back as to the birth of your child. Your response to these questions will help your child’s clinician better understand and care for your child. Answer each question to the best of your knowledge or memory.

Rows	No	Yes	Can't Remember	Don't Know
P1. Was he/she born before he/she was due (premature)?
P2. Were the doctors worried about his/her medical condition immediately after he/she was born?
P3. Did he/she have to spend any time in a neonatal intensive care unit (NICU)?
P4. Could he/she walk on his/her own by the age of 18 months?
P5. Has he/she ever had a seizure?
P6. Did he/she ever lose consciousness for more than a few minutes after an accident?

Rows	No	Yes	Can't Remember	Don't Know
P7. By the time he/she was age 2, could he/she put several words together when speaking?
P8. Could people who didn’t know him/her understand his/her speech by the time he/she reached age 4?
P9. Have you ever been concerned about his/her hearing or eyesight?
P10. By the time he/she was age 4, was he/she interested in playing with or being with other children?

Rows	No	Yes	Can't Remember	Don't Know
P11. Was there ever a time when he/she could not live at home and someone else had to look after him/her?
P12. Has he/she ever been admitted to the hospital for a serious illness?
P13. Does anyone at home suffer from a serious health problem?
P14. Does anyone at home have a problem with depression?
P15. Does anyone at home regularly see a counselor, therapist, or other mental health professional?
P16. Does anyone at home have a problem with alcohol, drugs, or other substances?
P17. Would you say that the atmosphere at home is usually pretty calm?

Rows	Less Than Once a Month	Between Once a Week and Once A Month	More Than Once a Week	Most Days
P18. How often are there fights or arguments between people at home?
P19. How often does your child get criticized to his/her face by other family members when he/she is at home?

Patient Name: {clientName}

Today's Date: {date41}

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Patient Name: {clientName}

Today's Date: {date41}

Rows	Yes	No
1. Has there ever been a period of time when:
…you were not your usual self (while not on drugs or alcohol)?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn't really miss it?
…you were much more talkative or spoke faster than usual?
…thoughts raced through your head or you couldn't slow you mind down?
…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? …spending money got you or your family into trouble?
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
3. Have any of your blood relatives had manic-depressive illness or bipolar disorder?
4. Has a health professional ever told you that you have manic- depressive illness or bipolar disorder?

Rows	None	Minor	Moderate	Serious Problem
5.How much of a problem did any of these cause you -- like being unable to work, having family, money, or legal troubles; getting into arguments or fights? __ None __ Minor __ Moderate __ Serious problem

Patient Name: {clientName}

Today's Date: {date41}

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 gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by amotor?
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?

Medication Management Questionnaires

Early Development and Home Background (EDHB) Form—Parent/Guardian

PHQ-9 & GAD-7

Mood Disorder Questionnaire (MDQ)

ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist