Initial-data-collection-ADHD

Identification

Patient

Type of health insurance:

sex : M W

Address

Contact

Phone to contact first

Family doctor

Pharmacy

Contexte familial

Father

Mother

Parents’ marital status (at childhood):

Patient’s marital status:

The patient lives with:

Is the patient adopted?

Yes No

Is the patient in or has he ever been in foster care?

Yes No

Does the patient have brothers or sisters?

Yes No

For each brother / sister, indicate:

Language spoken at home?

Pregnancy and birth history

Did the patient’s mother use or take any medications during pregnancy? (Check what applies)

Medication Alcohol Cigarettes Drugs

General Medical History

Date of last physical exam: (Leave blank if you don’t know)

Neurological History / Endocrinology

History – ENT / Pneumology

Repeated ear infections? Yes No

Sleep apnea?

Yes No

Asthma ?

Yes No

Hypertrophy of the Adenoids / Tonsils? Yes No

History – Cardio-Vascular

History – Development (early childhood)

History – Learning Disability

Background – Other statement

High potential / Giftedness / Mental retardation

Yes No

Is the patient experiencing medical complications caused by drugs or alcohol?

Yes No

Paramedical monitoring

Has the patient been or is he being followed by a specialist?

Yes No

Specify (Psychologist, Psychiatrist, Neurologist, Occupational therapist, Speech therapist, Special education specialist, social worker, specialized doctor, etc.)

Family history

Sleep

Does the patient have sleep problems?

Yes No

In general, during the week, the patient gets up around:

In general, during the week, the patient goes to bed around:

Generally, on weekends, the patient gets up around:

Generally, on weekends, the patient goes to bed around:

Typically, how long does it take for the patient to fall asleep? (Minutes or hours)

Typically, is the patient exposed to a screen before falling asleep? Yes No

School History

Is the patient studying?

Yes No

What type of class is the patient in?

What other school(s) have you attended before?

Describe the patient’s behavior in class.

Does the patient already have or use services at school?

Yes No

Has the patient already had or does he have an intervention plan in place?

Yes No

Has the patient ever been in detention?

Yes No

Has the patient ever been suspended?

Yes No

Has the patient already been expelled?

Yes No

Has the patient already doubled a year?

Yes No

Name the difficulties that the patient experiences or has experienced in her school career

Name the failures that the patient experiences or has experienced in her school career

Professional history

Does the patient have a professional history?

Yes No

Indicate the year, position, employer and a summary of duties

How many times have you been fired?

Medication

Indicate current and previous medications and natural products.

Indicate the Name, dosage, duration of treatment and result(s) or side effect(s)

Does the patient have difficulty swallowing pills?

Consultation

By clicking on “I understand and I accept” below, you agree that ExcelleMD collects all the personal information registered in this form (including personal health information of a potentially delicate nature) and uses it for the purpose of Evaluate, plan and possibly provide you with medical services. You consent to ExcelleMD discloses this information to third parties, if necessary to provide you with these services.

The information collected will be sent securely to Adobe servers to create a PDF.
The PDF will then be saved on ExcelleMD’s Microsoft Secure Servers and in ExcelleMD’s Electronic Medical Record software.
All personal information will be protected and kept in accordance with ExcelleMD privacy policy.

Please refer to our terms of use page for more details.

Please refer to our privacy page for more details.

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Initial data collection – ADHD

Identification

Patient

Address

Contact

Family doctor

Pharmacy

Contexte familial

Father

Mother

Pregnancy and birth history

General Medical History

Neurological History / Endocrinology

History – ENT / Pneumology

History – Cardio-Vascular

History – Development (early childhood)

History – Learning Disability

Background – Other statement

Paramedical monitoring

Family history

Check all that apply

Sleep

School History

Professional history

Medication

Consultation