ADHD Pre-Assessment Questionnaire

ADHD Pre-Assessment Questionnaire

Complete this questionnaire based on the reference document. Please answer all required questions and provide details where requested.
Patient Details and Contact Information
Full Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
Date
Address (including postcode)
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
GP Surgery Name and Address
Emergency Contact Name, Relationship and Telephone Number
Mental Health History and Safety
Have you ever been diagnosed with a mental health condition?
If yes, please list the diagnosis, approximate date diagnosed, and any treatment received
Are you currently taking any medication for mental health?
If yes, please list the medication name and dose
Have you ever engaged in self-harm?
Have you ever had thoughts of suicide or ending your life?
Have you ever attempted suicide?
If yes, please provide any details you are comfortable sharing
Have you experienced trauma or a distressing event?
If yes and comfortable, please describe the trauma or event
Substance Use, Physical Health, and Medical History
Alcohol use frequency
Smoking or vaping
Cannabis or other recreational/non-prescribed drug use
If yes, please briefly describe what substances you use, how much, and how often
Overall physical health
Current or previous physical health conditions
If yes, please list the condition(s) and any treatment
Prescribed medication, over-the-counter medication, supplements, or contraception
If yes, please list the name and dose of each
Allergies
If yes, please describe the allergy and reaction
Operations, surgery, or hospital stays
If yes, please provide details and approximate dates
Eyesight or hearing problems
If yes, please provide details
Epilepsy, seizures, fainting, or blackouts
If yes, please provide details
Hormonal or metabolic condition such as diabetes or a thyroid problem
If yes, please provide details
Family History, Current Symptoms, and Cardiovascular Screening
Serious health conditions in close biological family
If yes or unsure, provide details and specify which relative(s)
Are you currently troubled by any ongoing physical symptoms?
If yes, please describe the symptoms
Date of last general health check or GP visit
Do you have any heart problems such as palpitations, chest pain, fainting, or high or low blood pressure?
Do you experience breathlessness, dizziness, fainting, chest pain, or palpitations during exercise?
Did a close biological relative die suddenly or unexpectedly before age 40, or have a serious heart condition?
If yes or unsure, provide details
Sleep, Lifestyle, Reproductive Health, Measurements, and Additional Information
Usual sleep duration
Do you have difficulty sleeping?
Daily caffeinated drinks
Exercise frequency
Pregnancy, breastfeeding, or trying to conceive
Contraception or hormone treatment
If yes, please provide brief details
Height
Weight
Blood pressure
Pulse rate
Waist measurement
Date these readings were taken

MonthDayYear
Date
Anything else important for the clinical team to know
Declarations, Consent, and Completion
I agree that the information provided is accurate and complete to the best of my knowledge
I understand that urgent or emergency medical concerns should be addressed by emergency services or urgent medical help
I consent to the clinical team reviewing this information as part of my assessment and treatment
Do you consent to the clinic contacting your GP where clinically necessary for safe care?
Patient signature or typed name

First NameLast Name
Date completed

DayMonthYear
Date
Should be Empty:

ADHD Pre-Assessment Questionnaire

Patient Details and Contact Information

Mental Health History and Safety

Substance Use, Physical Health, and Medical History

Family History, Current Symptoms, and Cardiovascular Screening

Sleep, Lifestyle, Reproductive Health, Measurements, and Additional Information

Declarations, Consent, and Completion