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ADD Medical Questionnaire

This questionnaire is for clinicians to give to their patients. Clinicians are free to copy, edit and print it as they see fit. Responsibility for the copied or edited content rests solely with the clinician.

 

    
     
Patient's name: _________________________   Date of birth:  __ / __ / __    Date questionnaire filled out: __ /__ / __
     
     
Please answer:   yes/no/don't know (y/n/?)
     
Have you had any of the following? y/n/? Reason for the question
thyroid problems (which)?   thyroid problems can mimic ADHD
glaucoma?   stimulants can increase eye pressure in people with glaucoma
seizures?   stimulants may cause seizures in people who have already had them
been knocked unconscious?   brain injury can mimic ADD or make it worse
neurological disorder?   brain disorders can mimic ADD or make it worse
kidney problems?   kidney problems can reduce the excretion of stimulants leading to a build up in the bloodstream and brain
liver problems?   many medications are metabolized in the kidneys.  Some medications, like Strattera, may cause liver problems.
Migraines.  if so, what medication do you take for them, if any?   stimulants can cause headaches.  Triptans and serotonin medications may have dangerous interactions
heart problems?   stimulants are contraindicated in people with heart problems
high blood pressure?   stimulants may increase blood pressure. An increase in blood pressure medication may be required by patients taking stimulants or Wellbutrin (buprprion)
What is your blood pressure?  When was it last taken?   bring blood pressure down to normal before starting stimulants. be especially careful to monitor blood pressure regularly after starting stimulants or Wellbutrin in a patient who is being treated for high blood pressure.
Is your pulse is less than 50 per minute when resting?   may need cardiac work-up unless low pulse is from excellent physical conditioning
Is your pulse is more than 120 per minute when resting?   stimulants can further increase the pulse and are contraindicated in people with pulse this rapid
Did a blood relative die at an early age of heart problems?   this is a contraindication to taking stimulants since there may be a fatal genetic vulnerability.
Do you have twitches or tics?   twitches or tics may be made worse, better, or be unaffected by stimulants
     
Sleep - Do you...    
have difficulty falling sleeping?   chronic tiredness can mimic ADD or make it worse
difficulty staying asleep?   may be due to sleep apnea or depression
find yourself tired during the day, yawning a lot?   these symptoms may be caused by sleep apnea.  Overtiredness may make ADD symptoms worse or mimic ADD
do you nap at least a few times a week to stay alert?   this may be a sign of sleep apnea
awaken during the night feeling frightened?   this may be a sign of sleep apnea
do you snore?   slightly suggestive of sleep apnea
have you been observed to stop breathing during sleep,and then awaken with a start?   this is a symptom very suggestive of sleep apnea
Do you have sleep apnea?   sleep apnea may cause symptoms similar to ADD or make ADD worse
If so, what evaluation or treatment you have had for sleep apnea?   a sleep study may be indicated for those with major sleeping problems. If person is using CPAP (apnea sleeping aid), are they using it regularly and with good effect
     
Medication reactions    
Are you allergic to a medication (medication, reaction)?    
Have you had a bad reaction to a medication?    
Do you take an MAOI antidepressant medication?   stimulants and SSRI's are contraindicated in persons taking MAOI's
     
Do you take fish oil?   this is sometimes mildly helpful to people with ADD
Vitamin C?   this increases the excretion of amphetamines and thereby reduce its effect
Do you take an herbal medicine? If so which?   there are some interactions with stimulants    
Do you take over the counter medications (which)?   aspirin taken at the same time as stimulants can reduce the absorption of stimulants    
         
Substance history        
Have you been addicted to or abused drugs?   persons with such a history may require more careful oversight if stimulants are prescribed    
Have you used "speed" or uppers (Dexedrine or others)   the person's reaction to stimulant medication taken in the past may predict his or her response to its therapeutic use    
Have you ever taken a stimulant? What effect did it have on you?        
         
Drugs/alcohol        
Do you smoke marijuana fairly regularly?   marijuana often interferes with the use of medications for ADD.    
Do you smoke cigarettes or cigars (how many per day)?   an important health question, though not specifically related to ADD    
Do you drink caffeinated drinks (if so, how much per day)?   the combination of coffee and stimulants may obscure the stimulant's effects and may make side effects of stimulants worse    
Do you have at least one drink almost every day (how many)?        
Have you sometimes had too much alcohol  to drink?   stimulants may make it hard for a person to judge how much he or she is impaired (for driving, say) by alcohol    
Is there someone in your home who has abused drugs

 or who might use drugs prescribed for you?

   steps may need to be taken to secure a stimulant supply if there is someone in the home who may take them    
         
Females only        
Are you pregnant or planning to get pregnant?   stimulants may adversely affect fetal development    
Are you using protection against getting pregnant?   reduces concern about stimulant use if pregnancy is less likely    
Are you breast feeding or considering breast feeding?   stimulants are carried in breast milk and may adversely affect the infant    
         

What ADD medications are you taking now/have you  taken?

        
Name of medication #1:        
Strength of pill        
Number of pills per day        
Effects of the medication        
         
Name of medication #2:        
Strength of pill