ADHD Medication Review Questionnaire

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Personal Details
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May be used to identify you
Readings
Please add a recent blood pressure reading e.g. 120/80
Beats per minute

If you are not able to provide these readings now, please ensure you do this prior to attending your appointment.

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

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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: *
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Weiss Functional Impairment Rating Scale
Work: *
School/Education: *
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Family
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: *
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Work
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: *
School/Education
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: *
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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: *
Self-Concept
Feeling bad about yourself: *
Feeling frustrated with yourself: *
Feeling discouraged: *
Not feeling happy with your life: *
Feeling incompetent: *
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Social
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: *
Risk
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: *
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Privacy Consent

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