Village Family Clinic & Wellness Center

Available Forms

#1 NEW PATIENT - Mood disorder #2 NEW PATIENT- ADHD assessment #3 NEW PATIENT Health History form #4 NEW PATIENT - PHQ-9 #5 NEW PATIENT Epworth Sleepiness Scale #6 NEW PATIENT CUXOS Anxiety Scale *Binge eating disorder assessment *FOLLOW-UP FORM: Anxiety *FOLLOW-UP FORM: Depression MDQ follow-up Medication renewal form Rejection Sensitivity Dysphoria scale *FOLLOW-UP FORM: ADHD Patient survey

*FOLLOW-UP FORM: ADHD

Name: *

Date *

What prescription(s) do you need refilled today?

What pharmacy do you use? (Please include name and location of pharmacy) *

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

2. How often do you have difficulty getting things in order when you have to do a task that requires organization? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

3. How often do you have problems remembering appointments or obligations? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

6. How often do you feel overly active and compelled to do things, like you were driven by a motor? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

7. How often do you make careless mistakes when you have to work on a boring or difficult project? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

10. How often do you misplace or have difficulty finding things at home or at work? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

11. How often are you distracted by activity or noise around you? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

13. How often do you feel restless or fidgety? *

0 - Never

1 - Rarely

2 - Sometimes

3 - Often

4 - Very often

14. How often do you have difficulty unwinding and relaxing when you have time to yourself? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

15. How often do you find yourself talking too much when you are in social situations? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

16. When you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

17. How often do you have difficulty waiting your turn in situations when turn taking is required? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

18. How often do you interrupt others when they are busy? *

0 - Never

1 - Rarely

2- Sometimes

3 - Often

4 - Very often

How is your appetite? *

Lousy

Fair

Good

How often are you exercising? *

Never

1-2 days

2-3 days a week

4 or more days a week

How is your sleep quality? *

1=POOR 10=GREAT

Are you experiencing any challenges at home, work or school since your last visit? If so, please provide a brief summary. *

Have you experienced any positive changes at home, work or school since your last visit? If so, please provide a brief summary. *

Do you have any concerns about treatment? *

Thank you! Please press "submit" when you are finished.

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