Registration for ADHD Center of Connecticut

Thank you for taking the time to fill in the information requested on this form. By doing this, you will make it easier for us to get to know your child and his/her needs as well as formulate a treatment plan. If you are not sure of an answer, leave blank and we can discuss at the initial evaluation meeting.
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Patient's School Grade
Hand used for writing

Right HandLeft Hand
Eyeglasses?:

YesNo
If yes reason for glasses:
Date of last vision screen:
Parent /Guardian's Name*

First NameLast Name
Parent /Guardian's Email*
Parent /Guardian's preferred contact number*

Area CodePhone Number
Parent/Guardian's Occupation
Where does patient currently get their ADHD care/management?

The Center for Advanced PediatricsOther Pediatrician or Doctor/Center (ei. Psychiatrist, Therapist)Never been treated for ADHD
Referring Physician's Name (For Non-TCFAP Patients)
Referring Physician's Phone # (For Non-TCFAP Patients)

Area CodePhone Number
Referring Physician's Fax # (if known)

Area CodePhone Number
Referring Physician's address (For Non-TCFAP Patients)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Language (s) spoken in the home:
Birth History
Was your child adopted?

YesNo
If Yes, where was your child born?
If yes, how old was your child when he/she was placed in your care?
Medications taken during pregnancy
Born on time?

YesPremature (enter #weeks below)
# of weeks of pregnancy when patient born:
Delivery type:

VaginalCesarean (enter reason below)
Reason for Cesarean:
Birth Weight
Birth Length
Pregnancy/Birth/Post Birth complications? (jaundice, NICU etc.) Please explain:
Did any previous pregnancy result in a miscarriage?

YesNo
Communicaton (Receptive and Expresive Language):
Does your child have a speech or language problem?

YesNo
If yes, please describe:
When was the problem first noticed and by whom?
At what age was your child easily understood by others?
How does your child communicate?

GesturesSingle WordsShort PhrasesSentencesSign LanguageOther
Has your child seen a speech or language specialist. If yes, name and date (s) of test and results:
Has your child had an Audiological Exam (Hearing Test)? If yes, please give date of test and results:
How does your child respond to sound (voices or noises):
Developmental & Social History

Please answer when child met developmental milestones and describe issues with school and behavior.
Rolled over for the first time (around 3-4 months)

On timeLate
Sat up well (around 6-8 months)

On timeLate
Walked alone (10-16 months)

On timeLate
Talked (2 words) (18-24 months)

On timeLate
Toilet trained (2-3 yrs old)

On timeLate
Diet Problems:
Sleep Problems
At what age was your child easily understood by others?
Does your child often need to have things repeated to understand them?

YesNo
Does your child have difficulty following directions?

YesNo
Can your chiild remember a short message?

YesNo
Medical History
Hospitalizations
Surgeries
Allergies to meds and/or other
Is Patient currently on ADHD Medications?

YesNoNo, but has been in the past
Current Medications
Past Medications taken for MORE THAN 2 WEEKS
Are immunizations up to date for age?

YesNoNo, but working towardsNo, we have declined vaccinations
Vaccinations missed or refused:
If female, have menstrual cycles begun?

YesNoYes, but cycles irregular
Age menstrual periods begun:
Last menstrual period began (how many days ago)
Any concerns about menstruation?
Any other health problems?
Current Behaviors
Please check any of the following items that relate to your child's current behavior(s):

ShyImmatureWell behavedStubbornImpulsiveTemper tantrumsCries excessivelyTells liesThumb suckingHead bangingNail bitingMore active than othersClumsy using handsPoor handwritingClumsy walkingBlank spells or Fainting SpellsNoise or Touch SensitivityTics and TwitchingAlways in motionExcessively fidgetyDifficulty paying attentionDifficulty staying at one task for a long timeGets distracted while watching TVDifficulty with transitionsDifficulty with finishing a taskDisorganizedShows poor judgement in dangerous or questionable situationsPoor awareness of timeGets lost easily'Frequent accountsDestructive/AggressivenessDifficulty listeningGets easily frustratedHas poor self-esteemFears making mistakesEats paper, paints, etc.Moods change quicklyDifficulty understanding jokesSelf abusive behaviorWithdrawnStubbornPlays alone for a reasonable length of timePoor eye contactCooperativeAttentiveWilling to try new activitiesOther
Family History
Names, ages, gender of household members and family living in the home:
Names, ages, gender of household members and family living outside the home:
Who is the child's primary caregiver?
Who cares for the child when the primary caregiver is away?
Family Relations
Are there significant marital conflicts?

YesNo
If yes, describe briefly:
Is there conflict between child and parent?

YesNo
If yes, describe briefly:
Is there conflict between siblings?

YesNo
If yes, describe briefly:
Do parents agree on discipline?

YesNo
Who usually disciplines the child and how?
Does your child have difficulty getting along with adults?

YesNo
Does your child have difficulty getting along with siblings?

YesNo
Describe your child's relationship with his/her siblings:
Educational History
When did your child first start attending school (age):
What, if any, problems were reported at school?
List all prior schools attended and years of attendance:
Current school attending and grade placement:
Current teacher's name(s):
Has your child ever been held back a grade? If so, which grade(s)
Has your child ever been suspended from school? if so, how many times and when.
Special Ed/Placements (Include age placed in Special Education)
Please describe any private support/services your child receives:
What are your child's strengths and/or best subjects?
Is your child having difficulty with any subjects?
Describe your child's attitude towards school:
Has your child ever missed an extended amount of school? If yes, please explain:
Social Emotional Development
Describe your child's current social skills and peer relationships. Please note if your child has a history of being bullied/teased or has been aggressive in play with others.
How would you describe your child socially? How do you think your child interacts with peers while at school?
Does your child have a best friend?

YesNo
Please list your child's favorite hobbies, activities, games and other sports (ei. piano, books, dolls, crafts, etc. ) Also please describe how well you feel your child does in those areas.
Please list any additional organizations, clubs, teams or groups in which your child participates other than sports:
How does your child handle stress?
What are your child's strengths?
In what areas would you like to see your child stronger?
What are your goals for treatment?

Birth History

Developmental & Social History

Medical History

Current Behaviors

Family History

Family Relations

Educational History

Social Emotional Development