New ADHD Patient Paperwork

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Do you give consent for us to contact you via text and email for appointment reminders, office sales, and post appointment instructions? ( We do not share your information with any 3rd party sellers) * This field is required.
YESNO
5
Date of Birth * This field is required.
6
How did you hear about us? We give referral credits to patients. * This field is required.
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Do you have any medication allergies? * This field is required.
9
Do you have a family history of ADHD, ADD, or Autism spectrum disorder?* This field is required.Check one:
YESNO
10
Please list all current medications* This field is required.
11
Do you have a history of substance or alcohol abuse?* This field is required.
12
Can you concentrate when working, studying or completing tasks? * This field is required.
13
How often do you have difficulty getting things in order when you have to do a task that requires organization?* This field is required.
Never
Rarely
Often
Sometimes
Very Often
14
How often do you have problems remembering appointments or obligations?* This field is required.
Never
Rarely
Sometimes
Often
Very Often
15
How often do you have trouble wrapping up final details of a project, once the challenging parts have been done?* This field is required.
Never
Rarely
Sometimes
Often
Very Often
16
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?* This field is required.
Never
Rarely
Sometimes
Often
Very Often
17
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?* This field is required.
Never
Sometimes
Rarely
Very Often
Often
18
How often do you feel overly active and compelled to do things, like you were driven by a motor?* This field is required.
Never
Rarely
Sometimes
Often
Very Often
19
How often do you make careless mistakes when you have to work on a boring or difficult project?* This field is required.
Never
Rarely
Often
Very Often
Sometimes
20
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?* This field is required.
Never
Sometimes
Often
Rarely
Very Often
21
How often do you have difficulty concentrating on what people say to you, even when they are speaking directly to you?* This field is required.
Never
Often
Rarely
Very Often
Sometimes
22
How often do you misplace or have difficulty finding things at home or work?* This field is required.
Never
Rarely
Sometimes
Often
Very Often
23
How often are you distracted by activity or noise around you?* This field is required.
Never
Sometimes
Often
Very Often
Rarely
24
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?* This field is required.
Never
Very Often
Often
Rarely
Sometimes
25
How often do you feel restless or fidgety?* This field is required.
Never
Sometimes
Rarely
Often
Very Often
26
How often do you have difficulty unwinding and relaxing when you have time to yourself?* This field is required.
Never
Often
Sometimes
Very Often
Rarely
27
How often do you find yourself talking too much when you are in social situations?* This field is required.
Often
Rarely
Never
Sometimes
Very Often
28
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 themselves?* This field is required.
Never
Very Often
Rarely
Sometimes
Often
29
How often do you have difficulty waiting your turn in situations when turn taking is required?* This field is required.
Never
Sometimes
Rarely
Often
Very Often
30
How often do you interrupt others when they are busy?* This field is required.
Never
Sometimes
Often
Very Often
Rarely
31
Medical History: Please list all surgeries and major illnesses below* This field is required.
32
Medical Question: Have you ever been diagnosed with High Blood Pressure? * This field is required.
33
Padgett Medical Center's Terms & Conditions* This field is required.Padgett Medical Center's terms and conditions.
34
Padgett Medical Center's Terms & Conditions Signature* This field is required.
Clear
35
Padgett Medical Center's Telemedicine Consent Forms* This field is required.
36
Padgett Medical Center's Telemedicine Consent Signature* This field is required.
Clear
37
Padgett Medical Center's HIPPA Privacy Consent Form* This field is required.
38
Padgett Medical Center's HIPPA Privacy Consent Signature* This field is required.
Clear
39
Padgett Medical Center Permission to Treat Terms & Conditions* This field is required.
40
Padgett Medical Center ADHD Medication Terms & Conditions* This field is required.
41
ADHD Medication Terms & Conditions Signature * This field is required.
Clear
42
Preferred Pharmacy Name, Address, & Phone Number
43
Please Upload Florida ID or Drivers License Picture* This field is required.Please Upload ID Picture
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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44
Please Upload a Face Picture for Identity Purposes* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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