ADHD Assessment Form Template

Blank ADHD assessment template

Copy into the EMR or a Scribeberry custom template. Leave a line blank if you did not obtain it. Do not invent collateral.

Date / clinician / location:
Patient: [initials, age, sex]  |  Informant(s) present:
Visit type: screening / full diagnostic interview / medication review
Reason for assessment (patient's words):

Current symptoms (onset, course, settings)
Inattention (examples at home / school or work):
Hyperactivity / impulsivity (examples):
Age of onset (before 12 if DSM-5-TR; what is actually known):
Settings with impairment (home, school, work, peer, driving):
What has been tried (coaching, school plan, prior meds, therapy):

Developmental / academic / occupational history
Pregnancy, birth, early milestones:
School: grades, IEP/IPRC, detentions, tutoring, psychoeducational testing (year/result if known):
Work: job changes, performance reviews, driving record if relevant:

Collateral
Source (parent, partner, teacher SNAP/Vanderbilt, old report cards):
What they observed, and in which years:
Collateral not available because:

Differential and comorbidity screen
Sleep (hours, snoring, delayed phase, restless legs):
Mood / anxiety / OCD / trauma / psychosis symptoms:
Learning / language / autism traits (not a substitute for ADOS):
Substance use (caffeine, cannabis, alcohol, stimulants, other):
Medical: thyroid, concussion, seizure, hearing/vision, cardiac symptoms:
Family history: ADHD, bipolar, sudden cardiac death, substance use:

Exam / baseline (before stimulant discussion)
BP, HR, height, weight, BMI:
Cardiac symptoms or exam concern: Y/N — detail:
Appearance, MSE pertinent findings:

Scales used (name, informant, date) — scores recorded as reported, not reinterpreted:

Assessment
ADHD: not supported / possible, incomplete workup / diagnosed — presentation (inattentive / hyperactive-impulsive / combined)
Impairment statement (two settings, concrete):
Comorbidities / differentials still open:
Uncertainty / why not diagnosing today:

Plan
Further collateral or testing:
Non-medication (sleep, school letter, CBT/coaching referral, occupational):
Medication discussed, not started / started (drug, dose, monitoring):
Cardiac / BP follow-up:
Controlled-drug counselling if stimulant: storage, diversion, driving, follow-up interval:
Referral (psych, pediatrics, psychology) if indicated:
Safety-net and next visit:

CADDRA-aware workup in primary care

CADDRA (Canadian ADHD Resource Alliance) publishes clinical practice tools used widely in Canadian family medicine and psychiatry. The sequence is the same whether you are in Thunder Bay or downtown Toronto: confirm symptoms across time and setting, document impairment, look for comorbidity, then treat. The toolkit is not a licence to skip collateral in adults who 'always knew they had it.'

Adult first presentations are common in Canadian primary care. DSM-5-TR still wants evidence of symptoms before age 12. Report cards, a parent's memory, or a partner who knew the patient in school are more useful than a childhood you reconstruct from a 20-minute visit. If you cannot establish childhood symptoms, say so. 'ADHD traits, incomplete developmental history' is an honest assessment. 'Adult ADHD, start lisdexamfetamine' on a first visit with no collateral is not.

Child, adolescent, and adult — what changes

• Children: teacher collateral is expected. Ask about IEP, psychoeducational testing, hearing and vision, sleep, and how the classroom actually looks. Preschool diagnosis is specialist territory for most family physicians.
• Adolescents: add driving, substance use, academic drop-off, and whether symptoms are only during exam season. Get the teen alone for part of the visit.
• Adults: work function, parenting, driving, and comorbidity carry more of the visit. Do not treat a positive ASRS plus a request for a specific stimulant as a complete assessment.
• All ages: document functional impairment in at least two settings. Restlessness at home with straight As and no work problems is not the same as failing courses and losing jobs.

Psychoeducational testing can clarify learning disorders that sit beside ADHD. It is not required for every diagnosis. Order it when school function does not match the interview, when there is a language or giftedness question, or when the school will not put supports in place without it. ADOS belongs on a different page if autism is the question — do not collapse the two assessments.

Example — adult workup in family medicine

Reason: "I think I have ADHD. I was never tested as a kid."

Symptoms: Loses tasks mid-email, misses deadlines unless they are on fire, two verbal warnings at work this year. Reads the same paragraph three times. Fidgets in meetings. Interrupts partner. Onset: mother (phone, today) recalls unfinished homework and "daydreaming" from grade 3; report cards not available. Impairment: work performance plan; home — unpaid bills, two speeding tickets in 18 months. University completed with extensions.

Collateral: Partner of 6 years — consistent with above; not present in childhood. Mother as above. No teacher forms.

Sleep: 6–6.5 h, no snoring, delayed bedtime. Mood: no persistent low mood, no hypomania. Anxiety: work dread, no panic. Cannabis 2–3 nights/week. Alcohol weekends. No other stimulants. No concussion. No cardiac symptoms. Father had "focus issues," never diagnosed. No sudden cardiac death in family.

Exam: BP 124/78, HR 72, BMI 26. MSE: restless in chair, linear, no psychosis.

Scales: ASRS-5 positive (patient, today). Weiss impairment moderate at work and home.

A: ADHD, predominantly inattentive presentation — supported by adult function plus childhood collateral from mother. Incomplete school records. Cannabis and short sleep are contributors; not enough to explain the childhood story. Not diagnosing a learning disorder today.

P: Sleep schedule and cannabis reduction x 4 weeks in parallel, not as a delay tactic. Collateral: request old report cards. ECG not indicated on history/exam. Discussed methylphenidate vs lisdexamfetamine vs atomoxetine; patient prefers to try behavioural changes and coaching first. Referral: ADHD coaching; psychology if still considering testing. RTC 4 weeks with partner. Safety: no stimulant started today. Driving counselling documented.

Chart mistakes

• Writing 'ADHD' in the problem list after a screening questionnaire only.
• Starting a controlled stimulant on a first visit with no BP, no collateral, and no mimic screen.
• Copying scale scores without naming the informant.
• Using the same note for a child as for an adult and leaving school blank.
• Treating a request for a specific brand as the assessment.

Frequently asked questions