ADHD Medication Review Questionnaire

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Personal Details
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May be used to identify you
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Beats per minute

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You can submit these via the 'Contact Us' form on this website.

Side Effects

Please tick the option below which best indicates the frequency you are experiencing these side effects:

(Where relevant, please add a comment)

Headache: *
Dry Skin: *
Dry Eyes: *
Dry Mouth/Thirst: *
Sore Throat: *
Dizziness: *
Nausea: *
Stomach Ache: *
Vomiting: *
Sweating: *
Appetite Reduction/ Weight Loss: *
Diarrhoea: *
Frequent Urination: *
Tics: *
Sleep Problems: *
Mood Instability: *
Irritability: *
Agitation/Excitability: *
Sadness: *
Heart Palpitations: *
Sexual Dysfunction: *
Weiss Functional Impairment Rating Scale
Work: *
School/Education: *
Having problems with family: *
Having problems with spouse/partner: *
Relying on others to do things for you: *
Causing fighting in the family: *
Makes it hard for the family to have fun together: *
Problems taking care of your family: *
Problems balancing your needs against those of your family: *
Problems losing control with family: *
Problems performing required duties: *
Problems with getting your work done efficiently: *
Problems with your supervisor: *
Problems keeping a job: *
Getting fired from work: *
Problems working in a team: *
Problems with your attendance: *
Problems with being late: *
Problems taking on new tasks: *
Problems working to your potential: *
Poor performance evaluations: *
Problems taking notes: *
Problems completing assignments: *
Problems getting your work done efficiently: *
Problems with teachers/tutors/lecturers: *
Problems with school/education administrators: *
Problems meeting minimum requirements to stay in school/education: *
Problems with attendance: *
Problems with being late: *
Problems with working to your potential: *
Problems with inconsistent grades: *
Life Skills
Excessive or inappropriate use of internet, video games or TV: *
Problems keeping an acceptable appearance: *
Problems getting ready to leave the house: *
Problems getting to bed: *
Problems with nutrition: *
Problems with sex: *
Problems with sleeping: *
Getting hurt or injured: *
Avoiding exercise: *
Problems keeping regular appointments with doctor/dentist: *
Problems keeping up with household chores: *
Problems managing money: *
Feeling bad about yourself: *
Feeling frustrated with yourself: *
Feeling discouraged: *
Not feeling happy with your life: *
Feeling incompetent: *
Getting into arguments: *
Trouble cooperating: *
Trouble getting along with people: *
Problems having fun with other people: *
Problems participating in hobbies: *
Problems making friends: *
Problems keeping friends: *
Saying innapropriate things: *
Complaints from neighbours: *
Aggressive driving: *
Doing other things while driving: *
Road rage: *
Breaking or damaging things: *
Doing things that are illegal: *
Being involved with the police: *
Smoking cigarettes: *
Smoking marijuana: *
Drinking alcohol: *
Taking "street" drugs: *
Sex without protection (birth control, condom): *
Sexually inappropriate behaviour: *
Being physically aggressive: *
Being verbally aggressive: *

Privacy Consent

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