An adult ADHD assessment records the evidence for and against ADHD: current symptoms, childhood onset, impairment, other causes, and the plan. Copy the free template, see a lifelong combined presentation and a late-onset case that turned out to be depression, and check what each part needs.
Blank adult ADHD assessment template
FreeADULT ADHD ASSESSMENT Patient: [Name, age, pronouns] Date of assessment: [Date, and number of sessions] Format: [In person, video, or phone] Clinician: [Name, credentials] REFERRAL QUESTION Referred by: [Clinician, self, school, or employer] Question asked: [Diagnosis, medication advice, or workplace or school supports] Why now: [What prompted the assessment] Earlier assessment or treatment: [Past ADHD assessments, diagnoses, or medication, or none] Sources of information: [Patient, informants with consent and their relationship, records reviewed] CURRENT SYMPTOMS Inattention: [Each symptom present in the past 6 months, with a real-life example] Hyperactivity and impulsivity: [Each symptom present in the past 6 months, including inner restlessness, with an example] Settings: [Where the symptoms show up: work or school, home, relationships, driving, money] Coping and supports: [Alarms, lists, apps, or other people's help that hide the symptoms] CHILDHOOD HISTORY Onset: [Earliest symptoms and the age they began, before 12 or not] School reports: [Report cards or teacher comments, with school years] Informant account: [What a parent, sibling, or other person who knew the patient before 12 describes] Development and education: [Milestones, learning support, grades repeated, highest level completed] Missing evidence: [Records or informants not available, and why] FUNCTIONAL IMPAIRMENT Work or study: [Performance, warnings, missed deadlines, job changes, unfinished courses] Home and relationships: [Bills, chores, parenting, conflict] Safety: [Driving incidents, injuries, risky decisions] RATING SCALES Self-report: [Scale and version, date, score, and what it shows] Collateral: [Scale, who completed it and their relationship, date, score] Structured interview: [Name of interview used, and the result, or not used] Other measures: [Mood, anxiety, sleep, and substance screens, with scores] DIFFERENTIAL AND CO-OCCURRING CONDITIONS Mood: [Depressive and manic or hypomanic episodes, and when they began relative to the attention problems] Anxiety: [Worry or panic, and whether it explains the poor focus] Sleep: [Hours, insomnia, snoring or pauses in breathing, shift work] Substance use: [Alcohol, cannabis, stimulants, other drugs; screen score] Learning and development: [Reading, writing, or math difficulties; autism features] Medical: [Thyroid disease, head injury, seizures, hormonal changes, medications that affect attention] MEDICAL HISTORY FOR TREATMENT Cardiac history: [Chest pain, fainting, palpitations, breathlessness on exercise, known heart disease] Family cardiac history: [Sudden cardiac death at a young age, inherited heart rhythm problems, cardiomyopathy] Vital signs: [Blood pressure, heart rate, weight] Medications and allergies: [All medications and supplements, with doses; allergies] Other factors: [Pregnancy plans, glaucoma, tics, seizures, past eating disorder, past misuse of stimulants] MENTAL STATUS AND RISK Mental status: [Appearance, restlessness, speech, mood, affect, thought process] Risk: [Suicidal thoughts, self-harm, harm to others, and what was done] DIAGNOSIS Conclusion: [ADHD diagnosed or not; if diagnosed, the presentation and severity] Evidence: [Symptom counts, onset before 12, settings, impairment, and why other causes don't explain it better] Co-occurring conditions: [Other diagnoses that need their own treatment] PLAN Psychoeducation: [What was explained, and resources given] Medication: [Options discussed, choice, starting dose, baseline checks, what to watch for] Therapy and skills: [CBT for adult ADHD, coaching, or other] Work or school supports: [Adjustments, letters, the patient's choice about telling the employer or school] Other conditions: [Plan for mood, sleep, substance use, or medical problems] Follow-up: [When, and the checks to repeat at each visit] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient psychiatry, new referral, two in-person sessions of 60 minutes
32-year-old man, account manager at a building supply company, lives with his partner. Referred by his family physician: does he have ADHD, and is medication suitable? Prompted by a written warning at work for missed client follow-ups. No earlier assessment or treatment. Sources: the patient over two sessions; his mother by phone and his partner, both with his consent; his school report cards from grades 2 to 7.
Inattention, 7 of 9 areas in the past 6 months: misses details in orders, drifts off in meetings, starts quotes and leaves them half done, puts off long reports until the night before, loses his phone and keys several times a week, is pulled off task by every message, and forgets client callbacks unless they’re in his phone. Hyperactivity-impulsivity, 6 of 9: fidgets constantly, gets up during meetings, feels restless and “driven,” talks a lot, answers before questions are finished, and cuts into others’ conversations. Present at work, at home, and while driving. Copes with phone alarms and a calendar his partner keeps for him.
Report cards, grades 2 to 7: “capable but rarely finishes his work,” “talks out of turn,” “needs reminders to stay in his seat.” His mother describes him from about age 6 as always on the go, losing jackets and lunch bags, and needing constant reminders; teachers called home most terms. Never assessed. Normal milestones; no grades repeated; finished a 2-year college business diploma, with extensions on most assignments.
Written warning 2 months ago; passed over for promotion. Three late fees on bills this year, so his partner now handles their money. Arguments at home over unfinished jobs. Two speeding tickets and one minor rear-end collision in 3 years, the collision while looking at his phone.
ASRS v1.1, self-report: Part A 5 of 6 items in the shaded range, a positive screen. CAARS observer form, completed by his partner: inattention T 72, hyperactivity-impulsivity T 68, both elevated. PHQ-9 5. GAD-7 6. AUDIT 4.
Depression: no depressive episodes. Bipolar disorder: no spells of high mood or little need for sleep; the symptoms are constant, not episodic. Anxiety: worry about his job since the warning, which came after the attention problems, not before. Sleep: 7 hours most nights, no snoring. Substance use: cannabis most weekends in his early 20s, none for 5 years; 4 to 6 drinks a week. Learning: reads well, never needed learning support. Thyroid: TSH normal 3 months ago. No head injury or seizures. None of these explains a pattern present since early childhood.
No chest pain, fainting, palpitations, or breathlessness on exercise; no known heart disease. No family history of sudden cardiac death, inherited heart rhythm problems, or cardiomyopathy. BP 122/78, HR 72, weight 84 kg. No regular medications; no known drug allergies. No glaucoma, tics, seizures, or eating disorder. Has never misused stimulants. ECG not needed, given the normal cardiac history, blood pressure, and heart rate.
Casually dressed, good rapport. Fidgety; shifted in his chair and stood up twice. Speech fast, interrupts at times. Mood “frustrated”; affect full range. Thought process tangential at times, easily redirected. No suicidal thoughts, self-harm, or thoughts of harming others.
ADHD, combined presentation, moderate. At least 5 symptoms in each domain over the past 6 months; several present before age 12, confirmed by report cards and his mother; present at work, at home, and on the road; clear impairment in his job, money, and driving. Not better explained by mood, anxiety, sleep, or substance use. No co-occurring disorder found.
Diagnosis and reasoning explained; written information on adult ADHD given. Options discussed: a long-acting stimulant, or a non-stimulant such as atomoxetine. He chose long-acting osmotic-release methylphenidate, 18 mg each morning, increasing in 18 mg steps no faster than weekly, guided by benefit and side effects. Told to expect possible reduced appetite, trouble sleeping, headache, and a faster heart rate, and to store the medication securely and never share it. BP, HR, and weight at every dose change. Referral to a CBT group for adult ADHD. He will decide whether to tell his employer; offered a letter supporting written task lists, fewer interruptions, and weekly check-ins with his manager. Follow-up by video in 2 weeks, then every 2 to 4 weeks until the dose is settled; repeat the ASRS at 3 months. Letter to his family physician.
Outpatient psychiatry, referral from primary care, one session by video
45-year-old woman, project manager at a construction firm, married with a 15-year-old son. Referred by her family physician at her request: “I think I’ve had ADHD all along and it’s finally catching up with me.” Question: ADHD, and would a stimulant help? Problems began about 14 months ago. No earlier assessment. Sources: the patient; her husband and her older sister, with her consent; her school report cards.
For 14 months: loses her train of thought mid-sentence, rereads emails several times, forgets meetings, struggles to make decisions, and misplaces her keys. Before that, she ran large projects without trouble and was promoted twice. No restlessness, interrupting, or impulsive decisions; more irritable than before. Also low mood most days for about a year, less enjoyment, waking at 3 a.m. most nights, and tiredness. Problems at work and at home since they began.
Report cards, grades 1 to 8: “works carefully and independently,” with top marks most years. Her sister remembers her as “the organized one” who kept her own homework schedule; no concerns from teachers. No learning support. Engineering degree. No symptoms before age 12 by any source.
Two missed deadlines this quarter; her manager has raised concerns. Has stopped seeing friends and left her book club. Less patience with her son. Still manages the household finances without errors.
ASRS v1.1, self-report: Part A 4 of 6 items in the shaded range, a positive screen. CAARS observer form, completed by her husband: inattention T 61, hyperactivity-impulsivity T 46, neither elevated. PHQ-9 16. GAD-7 9. Insomnia Severity Index 19. AUDIT 6.
Depression: low mood, loss of enjoyment, early waking, fatigue, guilt, and poor concentration for about a year, beginning after her mother died; the attention problems started at the same time. Bipolar disorder: no spells of high mood or reduced need for sleep. Anxiety: worry about work since the problems began; not the main driver. Sleep: about 5 hours a night, early waking, night sweats; no snoring or pauses in breathing, per her husband. Hormonal: irregular periods and night sweats for a year, likely perimenopause. Substance use: 1 or 2 glasses of wine most evenings to help her sleep, up from weekends only. Thyroid: TSH, CBC, and ferritin normal last month. No head injury; no new medications.
No chest pain, fainting, or palpitations; no known heart disease; no family history of sudden cardiac death. BP 128/82, HR 76. No regular medications; no known drug allergies. Not planning a pregnancy.
Well groomed, looks tired. Calm and still throughout; no restlessness. Speech soft and slow. Mood “flat”; affect constricted, tearful when talking about her mother. Thought process logical; content of guilt about work. No suicidal thoughts, now or in the past; no self-harm.
ADHD not diagnosed. The attention problems began at 44, with no sign of symptoms before 12 in her school reports or her sister’s account, and no hyperactive or impulsive features. They began with a depressive episode and poor sleep, which explain them better. The positive ASRS screen reflects current symptoms, not their cause. Diagnoses: major depressive disorder, single episode, moderate; insomnia with early waking, with perimenopause and evening alcohol likely contributing.
Explained why this is not ADHD, why a stimulant is not indicated, and that concentration usually recovers as mood and sleep improve; she agreed with the plan. Start escitalopram 10 mg daily; discussed side effects, 4 to 6 weeks for full effect, and to report worse mood or any thoughts of suicide. Crisis contacts given: 988, call or text, or the nearest emergency department. Referral for CBT for depression and CBT for insomnia. No alcohol in the evenings; a fixed wake time. Letter to her family physician about perimenopause symptoms and treatment options. With her consent, a letter for her manager supporting a lighter workload for 6 weeks. Follow-up in 4 weeks with the PHQ-9 and Insomnia Severity Index. Repeat the ASRS once her mood has recovered; if concentration problems remain then, reassess for other causes.
Who is asking, what they want to know, and where your information comes from.
Avoid: Leaving out the sources. A reader needs to know whether the childhood evidence came from records, a parent, or memory alone.
Inattention and hyperactivity-impulsivity over the past 6 months, each with a real-life example, in at least two settings.
Avoid: A symptom count with no examples. “Forgetful” means little; “misses client callbacks unless they’re in his phone” shows the pattern.
The evidence that symptoms began before age 12, from as many sources as you can get.
Avoid: “Childhood onset confirmed” with no source. Say who described what, and note when records weren’t available.
What the symptoms cost the patient, in concrete terms.
Avoid: Recording distress without impairment. Feeling disorganized is common; the diagnosis needs a clear effect on daily life.
Scores from standardized scales, with who completed them and when.
Avoid: Copying scale items into the note. Record the scale and version, who completed it, the date, and the score.
Other conditions that cause poor attention, and conditions that occur alongside ADHD and need their own treatment.
Avoid: “Differential considered.” Name each condition and the reason it does or doesn’t explain the symptoms.
What you need before choosing a medication, recorded whether or not you prescribe today.
Avoid: An ECG for everyone, or for no one. Base it on the cardiac history and vital signs, and write the reason.
Your conclusion, the evidence for it, and the treatment agreed with the patient.
Avoid: A conclusion without the reasoning. If you rule ADHD out, say why, and what you will treat instead.
The ASRS v1.1 is a screen. A positive Part A shows symptoms are present now; it doesn’t show they began in childhood, or that depression, anxiety, or poor sleep isn’t causing them.
Many adults are first recognized in adulthood, but their symptoms began in childhood. When the history shows symptoms starting in adulthood, say so: that points away from ADHD.
Ask about past spells of high mood and little need for sleep before starting a stimulant, and record when depression, anxiety, sleep problems, substance use, or thyroid disease began relative to the poor focus.
Record the cardiac history, family history of sudden cardiac death, blood pressure, heart rate, and weight before the first dose, and repeat the vital signs and weight at each dose change.
“ADHD” alone gives the next clinician no baseline. State combined, predominantly inattentive, or predominantly hyperactive-impulsive, based on the past 6 months, and the severity.
Vero Scribe writes the ADHD assessment in your template from the interview, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The referral question and sources; current symptoms of inattention and hyperactivity-impulsivity, with examples from at least two settings; evidence of onset before age 12; functional impairment; rating scale scores; the differential and co-occurring conditions; the medical history that affects treatment; the diagnosis and presentation; and the plan. The template follows that order.
Ask for school report cards, and an account from a parent, older sibling, or someone else who knew the patient before age 12. When none are available, record the patient’s concrete examples by age and school year, and note what was missing. Late recognition is common; late onset points away from ADHD.
Ask about chest pain, fainting, palpitations, and breathlessness on exercise, and about sudden cardiac death or inherited heart conditions in the family. Record blood pressure, heart rate, and weight. Arrange an ECG or a cardiology opinion when the history or vital signs raise concern. Ask about substance use, pregnancy plans, and other medications, and repeat the vital signs at each dose change.
A psychiatric evaluation is the full first assessment for any problem. An adult ADHD assessment answers one question in depth: it adds childhood evidence, collateral accounts, rating scales, and the cardiac checks for medication. When a referral raises several problems, start with the full evaluation.
Yes. Copy it, or download it as a Word or text file. No account needed.
The full first psychiatric assessment, with a structured mental status exam and a risk formulation.
The MSE on its own, in standard order, with normal and abnormal words for each domain.
Follow-up and medication management visits, tracked by target symptoms, side effects, and risk.
The psychiatrist’s ED or ward consult: the question, sources, medical contributors, MSE, risk, capacity, and numbered recommendations.
Assessments, follow-ups, and letters, drafted from the visit for your review.
The criteria by age, onset, setting, and impairment, and the evidence each one needs.
Common codes for ADHD and the conditions that occur alongside it.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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