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ADHD CARE PACKAGE CLINIC DOCUMENTATION
Patient Name:
DoB CHI:
Sys
tolic
Dia
stol
ic
Visi
t 1Vi
sit 2
Visi
t 3Vi
sit 4
Visi
t 5Vi
sit 6
Visi
t 7Vi
sit 8
Visi
t 9Vi
sit 1
0Vi
sit 1
1Vi
sit 1
2
Hei
ght (
cm)
Wei
ght (
kg)
Pul
se
Age
(yea
rs)
DU
ND
EE
BL
OO
D P
RE
SS
UR
E C
HA
RT
Titration Continuing Care Asked to See
Name of Clinician(s)
Appointment Type (tick one)
Visit 1
Clinicians
Visit Appointment Attended by
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer / ( )
Child / Parent / Carer/ ( )
Child / Parent / Carer / ( )
Date
Hello
Patient’s Details
Name:
DoB CHI:
Date of �rst visit:
Visit 2
Visit 3
Visit 4
Visit 5
Visit 7
Visit 8
Visit 6
Visit 10
Visit 11
Visit 9
Visit 12
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Visit 7
Visit 8
Visit 6
Visit 10
Visit 11
Visit 9
Visit 12
Visit
Summary and planVisit 7:
Visit 8:
Visit 9:
Visit 10:
Visit 11:
Visit 12:
Weight / Growth ok? - Yes / No
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Parent/Carer View
Overall Progress & Problems
Child View
Visi
t 1
Visi
t 2
Visi
t 3
Visi
t 4
Visi
t 5
Visi
t 6 V
isit 7
Visi
t 8
Visi
t 9
Visit
10
Visi
t 11
Visi
t 12
Summary and planVisit 1:
Visit 2:
Visit 3:
Visit 4:
Visit 5:
Visit 6:
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Clinician Signature: Date: Review in................ months
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Weight / Growth ok? - Yes / No BP ok? - Yes / No
Other Symptoms
Insomnia or troublesleeping
Nightmares
Drowsiness
Nausea
Anorexia / less hungry than other
children
Stomach aches
Headaches
Dizziness
Sad / Unhappy
Prone to crying
Irritable
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
Write Notes Visit 1:
Write Notes Visit 3:
Write Notes Visit 2:
Write Notes Visit 4:
Write Notes Visit 5:
Write Notes Visit 7:
Write Notes Visit 6:
Write Notes Visit 8:
Write Notes Visit 9:
Write Notes Visit 11:
Write Notes Visit 10:
Write Notes Visit 12:
Thoughts of self-harm
Suicidalideation
Euphoric / unusually happy
Anxious
Tics or nervous movements
“Spaced-out” / “Zombie-like”
Less talkative than other children
Less sociable than other children
Visits
Dr Christopher Lim, Dr Lilia Gomez Flores and Prof David Coghill, 2015
CGAS
Medication Name / Dose
Visit 1
Recommend
Visit 2
Recommend
Visit 3
Recommend
Visit 4
Recommend
Visit 5
Recommend
Visit 6
Recommend
Medication current taking / recommended (If none, write none)
Visits
Response to Treatment Scores
Inattention Total Hyp-Imp Total Total Score SKAMP
/9 =
Visi
t 1
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visit 7
Recommend
Visit 8
Recommend
Visit 9
Recommend
Visit 10
Recommend
Visit 11
Recommend
Visit 12
Recommend
Visi
t 2
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 3
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 4
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 5
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 6
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 7
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 8
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t 9
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
Visi
t10 Inattention Mean Score (total/6 ):
Deportment Mean Score (total/4):
Visi
t11 Inattention Mean Score (total/6):
Deportment Mean Score (total/4):
Visi
t12
Inattention Mean Score (total/6):Deportment Mean Score (total/4):
/9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/9 = /9 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
/18 =
1 2 3 4 5 6 7 8 9 10 11 12
Not Present 1 Present but not impairing2
Present & impairing3Key:
Medication Name / Dose Medication Name / Dose
3
2
1
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