ADULT 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]