Adult ADD

Here is a template of the email (or letter if you prefer to avoid email) I send to new patients after talking with them on the phone and making an appointment.  It is made up of three sections:

• Appointment confirmation
• Brief description of the evaluation session and follow up plans
• Fees
• Insurance
• Policy regarding missed appointments
• Directions to office
• Demographic, emergency, payee, and insurance information
• Clinical questionnaires (symptoms, medical history, family history, personal history, medication history)

============================================================

Hello Mr/Ms. ,

Thanks for having called to make an appointment with me.  This is to confirm the time as Monday March 22 at 10 AM.  Please try to arrive early just in case there are traffic or other unanticipated problems getting to my office.

The initial evaluation session lasts about 50 minutes. If I determine that you have ADD and there are no reasons not to, I will discuss with you the benefits and risks of taking an ADD medication, which I have found to be the most efficient and effective treatment of ADD.  I may also suggest coaching, therapy, or other approaches.

If I prescribe medication, I will see you for follow up sessions two and four weeks later. There may be brief phone sessions between office visits.  Improvement is generally fairly rapid, but it may require two or three or more sessions to find an optimal treatment for you.  Although this evaluation and treatment program is usually helpful, I can offer no assurance that I will make the diagnosis of ADD or find the right medication or treatment for you.

My fee for the initial 50 minute consultation is $xxx. The charge for sessions thereafter is $xxx (15 minutes), $xxx (25 minutes), or $xxx (50 minutes).  It generally requires two or three sessions after the evaluation to fully stabilize the treatment program.

I am not in any insurance networks so only if you have “out of network” coverage can you get insurance assistance in paying for sessions with me.  You can call your insurance carrier if you are not sure whether you have such coverage.

I will invoice you for the first session via PayPal.  Kindly pay at the time your receive the invoice.  Sessions after the first one can be paid for at the beginning of the session by check or cash or before the session via PayPal.

It has been my experience that patients with ADD not infrequently forget appointments, miss appointments, or have trouble getting to appointments on time.  For this reason, I have made it a policy to charge in full for follow-up appointments that are missed or canceled less than three  working days before the scheduled visit.  I will usually send you an email or text message reminder of your appointments a few days before we are scheduled to meet to minimize the likelihood of this happening, but please don’t rely on the reminders as there may be times when I will not be able to send one.

As you know, I see patients only for consultation, diagnosis, and initial treatment of Attention Deficit Disorder.  Once we have worked out an effective treatment program, I ask patients to obtain their on-going ADD management from their primary care clinician.  This is often more convenient and less expensive for them than seeing me.

Here are the directions to my office.  The experience of many new patients leads me to suggest that you not rely on a Global Positioning Device.
(Directions)
First Name, Last Name
Address (Street)
City, State, ZIP

Cell number:
Other number, if any:

email address:

Out-of-Network Insurance Information
SSN:
Managed care company:
Name of plan:
Phone number of plan:

If insurance is through employment, name of employer:
Insurance group number:
Name of insured:
SSN of insured:
Relationship of patient to insured:

Name of person (if not patient) responsible for payment:
Address line 1 of person responsible for payment:
Address line 2 of person responsible for payment:
City, State, ZIP of person responsible for payment:

Home phone number of person responsible for payment:
Work phone number of person responsible for payment:

Patient’s relationship to the person responsible for payment:

Emergency Contact Information
Person to contact in case of emergency:
Relationship of emergency contact to patient:

Home phone number of emergency contact:
Work phone number of emergency contact:
Pager phone:

Pharmacy Information
Pharmacy usually used by the patient:
Phone number:
Address:
City, State,  ZIP:

Pharmacy also used by the patient:
Phone number:
Address:
City, State  ZIP:

Clinical Notes:

Patient name:

Source of referral:
Reason for referral:

Date(s) of evaluation visit(s): Leave blank

CPT of session: 90801

Gender:
Date of birth:
Age:
Occupation:
Marital status:
Spouse/partner name:
Spouse/partner occupation:
Children:

ADD Symptoms:
Please give your score for the severity of your symptoms at the beginning of each line of the questionnaire.  Although it might be easier for you to enter your answer at the end of each question line, kindly put it at the beginning as this makes it possible for me to a computer sort of your responses and group them according to severity.  This is helpful diagnostically and also makes it easier to track the changes in your scores with treatment.

Scoring key
Doesn’t describe me at all, happens very rarely, no problem:         0
Describes me somewhat, happens sometimes, a mild problem:      1
Describes me pretty well, happens often, a moderate problem       2
Describes me very well, happens usually, a severe problem:          3

After entering your score for each item, press the down arrow once and the left arrow once.

Enter your score before the “>”.  For example, for the item…
>  I have trouble remembering telephone numbers
Enter your answer, for example “2″ as follows:
2< I have trouble remembering telephone numbers

PROCRASTINATION
< I remember to do things but still only do them at the last minute or when it’s too late
< I wait until the last moment before starting tasks

MAINTAINING FOCUS
< I lose the thread of a story someone is telling me.
< I go from topic to topic when I talk

PERSEVERANCE
< I have trouble doing tasks that require sustained mental effort
< I don’t follow through on promises or commitments

COMPLETING TASKS
< I have trouble wrapping up the final details of a project
< I  don’t follow through or finish my work

INTERNAL DISTRACTIBILITY
< I am easily distracted by my own thoughts
< I often lose my concentration if a conversation goes on for more than 5 or 10 minutes
< I can’t keep my mind on what I am doing because I keep thinking of other things

EXTERNAL DISTRACTIBILITY
< I have trouble concentrating when things are going on around me

TASK FORGETFULNESS
< I forget to do things I have in mind (to do, buy)
< I have to go back into my home or work to get things I forgot

READING ATTENTION
< My mind usually wanders while I am reading
< I rarely finish a book I have begun

LATENESS
< If it’s up to me, I don’t pay my bills on time
< I don’t have a system for paying bills
< If I’m on my own, I am  late to arrive at social gatherings

APPOINTMENTS
< I don’t write appointments down
< I don’t have a reminder system for appointments
< I forget appointment times
< I am late for appointments

PLANNING
< I don’t prioritize or plan my day
< I have trouble making plans long in advance

THOUGHT ORGANIZATION
< I have trouble writing an outline
< I  have difficulty stating a problem clearly
< I can’t work well without clear guidelines or instructions
< I have trouble doing things in the proper order or sequence
< I get lost in details and lose sight of the big picture

DETAILS
< I don’t give close attention to details and make careless mistakes
< I leave lights on, leave clothing drawers open, or leave the tops of bottles off

MESSINESS
< I can’t find things I have filed or stored
< I misplace things necessary for tasks
< My personal work area is messy

IMPULSIVITY
< I do things without thinking about the negative consequences
< I am likely to drive a motor vehicle faster than others on the road
< I am impulsive

INTERPERSONAL IMPATIENCE
< I interrupt others when they are talking
< I blurt out answers before the question has been completed

HYPERACTIVITY
< Even if I’m not bored, I need to keep walking, moving around
< I feel on the go, driven by a motor
< I talk too much

PHYSICAL SIGNS
< I have a slight tremor
< I can’t draw straight lines because my hand is not steady enough

HYPERFOCUS
< I find it hard to stop doing a task I am interested in
< If something captures my attention, it is hard for me to let go of it

HYPER COGNITION
< There is always one thought after another going thought my mind
< I have trouble getting to sleep because my thoughts won’t stop

SYMPTOMS’ EFFECTS (score from   0 = none at all    to   3 = frequently or severely)
< My symptoms interfere with my work or schooling
< My symptoms interfere with my family relationships
< My symptoms interfere with my personal relationships
< My symptoms lower my self esteem
< My symptoms make me anxious
< My symptoms make me depressed

PERSONAL HISTORY
Please answer Y or N.   Enter “?” if you are unsure about the meaning of the question or about your answer or would like to discuss it with me when we meet.

As a child…
< I had to repeat one or more grades
< I fidgeted a lot, couldn’t sit still
< I was distractible, had a short attention span
< I had a lot of discipline problems
< I never did as well as I should have in school
< I was held back in school
< I was treated for ADD

Adult history
< I have had to change jobs often
< I have been fired from jobs because of performance problems
< I have had periods when I overspent
< I have had periods where I gambled too much
< I have had periods when I was overactive physically
< I have had periods when my mind raced
< I need a lot of caffeine to get going at the start of the day
< I think so much that I have trouble getting to sleep
< I have been diagnosed as having ADD. If so, details:
< I have been treated for ADD.  If so, details:
< I have been hospitalized for a psychiatric disorder
< I have been given one or more tickets for speeding If so, how many?
< I was driving a car when it was totaled
< I have been in one or more “fender benders”. If so, how many?

ADD Family History
< I have a blood relative who has ADD. If so, which?
< If the relative has been successfully treated with medication, which?

Medical History
Name of personal physician:

Date of last physical exam:

Abnormal findings from the exam, if any:

Do have a history of….
thyroid problems (which)?
glaucoma?
seizures?
been knocked unconscious?
passing out for no reason?
neurological disorder?
kidney problems?
liver problems?
migraines.  if so, what medication do you take for them , if any
heart problems now or in the past?
high blood pressure?
Tourettte’s syndrome or tics?
Sucrose/glucose/fructose intolerance?

What is your blood pressure? When was it last taken?
Is your pulse is less than 50 per minute when resting?
Is your pulse is more than 120 per  minute when resting?
Did a blood relative die at an early  age of heart problems?
Do you engage in strenuous activities that make you sweat a lot?
Do you have twitches or tics?

Do you…
have difficulty falling sleeping?
have difficulty staying asleep?
find yourself tired during the day, yawning a lot?
Do you nap at least a few times a week to stay alert?
Do you awaken during the night feeling frightened or short of breath?
Snore?
Have you been observed to stop breathing during sleep, and then awaken with a start?
Do you have sleep apnea?
If so, what evaluation or treatment you have had for it?

Medication reactions
Are you allergic to a medication ?( specify medication, reaction)
Have you had a bad reaction to a medication?
Do you take an MAOI antidepressant medication?

Do you take fish oil?
Vitamin C?
Do you take an herbal medicine? If so which?
Do you take over the counter medications (which)?

Substance history
Have you been addicted to or abused drugs?
Have you used “speed” or uppers (Dexedrine or others)
Have you ever taken a stimulant?  What effect did it have on you?

Drugs/alcohol
Do you smoke marijuana fairly regularly?
Do you smoke cigarettes or cigars (how many per day)?
Do you drink decaffeinated drinks (if so, how much per day)?
Do you have at least one drink of alcohol almost every day (how many)?
Have you sometimes had too much alcohol to drink?
How many times in the past year have you drank more than four drinks in one day?
Is there someone in your home who has abused drugs or who might use drugs prescribed for  you?

Females only
Are you pregnant or planning to get pregnant?
If sexually active, are you always using protection against getting pregnant?
Are you breast feeding or considering breast feeding?

Psychological functioning
Are you…
often anxious, worried, nervous?
often depressed, sad, unhappy?

Have you…
ever been excessively suspicious or paranoid?
ever heard voices, had strange beliefs?
ever had a manic or depressive episode?
been given a diagnosis of obsessive-compulsive disorder?

Have you taken psychological tests, personality tests, ADD tests?
If so, could you please bring a copy of them with you to your session.

Do you often take or have you often taken
anti-anxiety medication?
anti-depressant medication?
any other psychiatric medication?
blood pressure medication?
steroids?
antacid medications?

What other medications are you taking now, if any? Specify strength of pill and daily dose if known:

History of emotional disorder/substance dependency, treatment and outcome in blood relatives:

Previous psychological illness, treatment, and outcome:

Will you be taking blood or urine tests for amphetamines in your job?

Thanks very much for completing the questionnaire.   Kindly email it back to me when you have completed it.