Adult ADHD Medical History Form

Adult ADHD Medical History Form

(If you have already submitted this form, there is no need to do it again.)
This form will ask the following:
- basic contact information
- medical history
- if you wish to inform your GP and, if so, their email address
- upload a copy of your photo ID and a recent (< 3 months old) utility bill
- ask you to upload as many supporting documents as possible (e.g. GP Summary, School Reports, Previous Assessment Reports)
- details of your Nominated Familiar Person (NFP)
You can send supporting documents and details of your NFP later and, but that may slow down your assessment readiness.

It should take you about 10 - 15 minutes to complete. Please have the files you wish to upload available on the device you use to complete this form (e.g. mobile phone or desktop computer). Please plan to complete the form in one sitting, because changes cannot be saved for later.
Section 1: Patient Contact Details
Name*

First NameLast Name
Mobile Number (This is the number we will use to WhatsApp video call you)*
07nnn nnnnnn
Email Address*
example@example.com
Date of Birth (e.g. 31 10 1990) *

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal Code

Section 2: Assessing Coexisting Conditions
2.1 Do you currently experience any persistent or frequent feelings of anxiety, worry, or panic attacks?*

NoYes
If yes, please describe.
2.2 Over the past two weeks, have you felt down, depressed, or hopeless?*

NoYes
If yes, please describe.
2.3 Do you experience extreme or sudden changes in your mood (e.g., shifts from happy/energetic to sad/irritable) that seem disproportionate to the situation?*

NoYes
If yes, please describe.
2.4 Have you ever been diagnosed with a mood disorder (like Bipolar Disorder), psychotic disorder (like Schizophrenia), or a substance use disorder?*

NoYes
If yes, please list the diagnosis and year.
2.5 Do you experience frequent sleep problems, such as difficulty falling asleep, staying asleep, or feeling unrested?*

NoYes
If yes, please specify (e.g., insomnia, restless legs).
2.6 Have you ever been formally assessed or diagnosed with Autism Spectrum Disorder (ASD)?*

NoYes
If yes, please describe.
2.7 Do you have any difficulties with social communication, such as understanding non-verbal cues, making eye contact, or understanding social rules?*

NoYes
If yes, please describe.
2.8 Do you have any history of difficulty with reading, writing, or mathematical skills that suggests a specific learning difficulty (e.g., Dyslexia or Dyscalculia)?*

NoYes
If yes, were you formally diagnosed? Please describe.
2.9 Do you or your family have a history of Tourette's syndrome or tic disorders?*

NoYes
If yes, please describe the types of tics.
Section 3: Assessing Other Physical Health Conditions
3.1 Have you ever had a history of epilepsy or seizures?*

NoYes
If yes, please give the date of the last seizure.
3.2 Do you have any current or past issues with your thyroid gland?*

NoYes
If yes, please describe.
3.3 Do you have a personal or family history of glaucoma?*

NoYes
If yes, please describe.
3.4 Do you have any known liver or kidney problems?*

NoYes
If yes, please describe.
3.5 Do you have a history of or current eating disorder such as anorexia?*

NoYes
If yes, please describe.
3.6 Do you have a history of stroke?*

NoYes
3.7 Do you have a history of high blood pressure?*

NoYes
3.8 Do you have a history of cardio vascular disease?*

NoYes
3.9 Are you currently taking any medications (including prescription drugs, over-the-counter medication, and supplements).*

NoYes
If yes, please list each medication, the starting date and dosage.
3.10 What is your height and weight? (To calculate BMI, which is monitored during treatment).*
3.11 Do you have any difficulty sleeping?*

NoYes
If yes, please describe.
3.12 Why do you think you may have ADHD?*
3.13 Was there some significant event that prompted you to seek assessment for ADHD?*

NoYes
If yes, please describe.
Section 4: Informing your GP
We recommend you inform your GP that you've sought private ADHD assessment. We can inform them on your behalf, and send a copy of your report, provided you can supply your GP's current, valid email address.
Would you like us to inform your GP?*

NoYes
GP's Email Address*
example@example.com
Section 5: Patient ID and Supporting Documents
REQUIRED DOCUMENT UPLOADS

Please upload a copy of your photo ID (e.g. driving license or passport).
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Please upload a recent (< 3 months old) utility bill (e.g. bank statement, electric bill, council tax bill, mobile phone bill, etc.).
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Please upload as many supporting documents as possible. For example, GP Summary, School Reports, Previous Assessment Reports. If you don't have them to hand, you can email them to us at a later date. However, the more supporting documents we have, the quicker and more accurate will be the diagnosis.
Cancelof
Cancelof
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Section 6: Nominated Familiar Person
Your Nominated Familiar Person (NFP) is someone who knows you well and can provide objective, detailed information about your behavior, functioning, and history across different settings.

Key characteristics of the NFP:
1. Close and Long-Term Relationship: The NFP must have had close contact with the patient, ideally over a significant period of time (e.g., several months to years).
2. Observation Across Settings: They should be someone who has observed the patient in multiple life domains (e.g., at home, socially, or in a professional environment) to confirm that symptoms are pervasive and not situation-specific.
3. Who is Suitable: The NFP is most often a spouse, long-term partner, close family member (e.g., parent or sibling), or a very close friend.
4. Informant Role: Their primary role is to complete standardised rating scales and provide a detailed history, particularly regarding symptoms present during childhood and how current symptoms impact the patient's daily life.

As part of the assessment, we will contact your NFP and ask them to complete a form answering questions about their observations of you. We recommend you let the person know that they will be contacted by us. Ideally, your NFP can also attend your assessment interview.

If you don't have a NFP identified currently, answer 'No' at this point, and you can send us their details at a later date. However, this will delay the time until you are 'assessment ready'.
Do you have a Nominated Familiar Person who can complete a form and ideally attend your assessment interview?*

NoYes
Informant/Collateral Source Full Name (Ideally a parent, older sibling, or long-term partner.)*

First NameLast Name
Relationship to Patient*
Familiar Person Mobile Number*
07nnn nnnnnn
Familiar Person Email Address
example@example.com
ADHD Assessment Terms, Conditions and Consent Form
Please read this document carefully before starting your ADHD assessment with us. By signing below, you confirm that you understand and agree to the terms, conditions and consent requirements outlined herein, which are designed to ensure the safe, efficient and effective management of your treatment.

1. Information Accurate and Complete

I confirm that the health history information provided on this form is accurate and complete to the best of my knowledge and recollection. I understand that withholding information or providing an incomplete history may be detrimental to my health and safety, and could impact the accuracy of my assessment and treatment plan. I agree to inform my healthcare provider immediately if there are any changes in my medical history or if I recall any additional relevant information.

2. Refund Policy

There are no refunds once the assessment process is initiated. Payment plans must be completed in full regardless of the outcome of the assessment.

3. Acknowledgement of Risks and Limitations
- I understand the risks and possible consequences involved in the treatment, and I acknowledge that no warranty or guarantee has been made regarding the results of cure. I recognise that such assessments are not an exact science and that reputable specialists cannot guarantee specific outcomes.
- I hereby authorise the specialist to administer treatment and agree to hold them free and harmless from any claims or suits for damages from any injury or complications that may result from this treatment.
By signing below, I confirm that I have read, understood, and agree to these terms and conditions, and that I consent to the treatment as outlined above.
Consent Signature*

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Adult ADHD Medical History Form

Section 1: Patient Contact Details

Section 2: Assessing Coexisting Conditions

Section 3: Assessing Other Physical Health Conditions

Section 4: Informing your GP

Section 5: Patient ID and Supporting Documents

Section 6: Nominated Familiar Person

ADHD Assessment Terms, Conditions and Consent Form