Dear Parents, - Rose Pediatrics

Dear Parents,

In order to evaluate your child for Attention-Deficit Disorder or Attention-Deficit /Hyperactivity Disorder (ADD/ADHD),

you will need to collect the material requested below. Once you have collected all the necessary materials, please call

our office to schedule an initial ADD/ADHD consultation. The initial appointment may last 40 minutes or more; please

plan accordingly. If ADD/ADHD medication is prescribed, your child will need to be seen for regular medication

rechecks as determined by your child’s provider. We ask that your child be present for all appointments and we also

request primary caretakers attend the initial consultation if possible.

You will need to collect information from your child’s teacher about school performance, classroom behavior and

concerns. We have also included a parent questionnaire to be completed by each parent. The check list below will

help you keep track of all the materials needed for your first appointment. The materials are kept strictly confidential

and will not be released without prior approval from you.

General Health Form Please fill out the enclosed questionnaire completely.

Patient History Form Please fill out to the best of your abilities.

Parent Questionnaire Please fill out completely, one questionnaire for each parent.

Teacher Questionnaire Send the enclosed teacher questionnaire to your child’s teachers.

Release of Information Form Please sign the enclosed release of information form and send it to your child’s school. BE SURE TO SIGN THE RELEASE OF INFORMATION FORM. If you do not, your children’s school will not be able to share information with us. This form gives the teachers permission to fill out the forms and send them in. It also gives Rose Pediatrics permission to speak directly with your child’s teachers, if necessary.

Individual Education Plan If your child has an Individual Education Plan (IEP) it’s critical we receive a copy of it. IEP’s are written with parent participation; if you are not familiar with this term, more than likely your child does not have an IEP. The enclosed release of information form gives the school permission to share your child’s IEP with us.

Medical History If we do not have information about your child’s previous medical care, please try to get copies of medical records sent to us as soon as possible. You can make this request from your previous medical office or request a form from our front desk.

Mental Health History If your child has required treatment for mental health problems, please provide us with records. This information is very important and will be kept strictly confidential.

Additional Therapy If your child has received or is receiving additional therapy outside of school, such as occupational therapy, physical therapy, or speech therapy, please provide a treatment summary for each.

Thank you for all your help. Feel free to contact our office if you have any questions regarding the attached questionnaires or the requested information. Sincerely, Rose Pediatrics

F: 303.393.7144

Rose Pediatrics Denver P: 303.320.7366 F: 303.320.7367

Rose Pediatrics Highlands Ranch P: 303.471.0221 F: 303.393.7144

ADD/ADHD Medication Policy

Please be aware of our policies regarding the management of your child’s ADD/ADHD medications.

These types of medications are generally classified as Schedule II controlled substances and are subject

to Federal and State regulation. Therefore, all patients on ADD/ADHD medications will be required to

have re-check appointments every 3 to 6 months as determined by your child’s provider (some cases

may require a sooner follow-up if instructed by your provider). This policy will be strictly enforced.

In addition, the Federal Drug Enforcement Agency regulates the manner in which a prescriber must

dispense these types of medications. Federal law prohibits prescribers from issuing refills in the same

manner as other medications. A separate prescription must be written for every 30 day supply. In 2008,

the DEA finalized a rule that allows prescribers to issue separate “Do Not Fill Until [date]” prescriptions

for Schedule ll controlled substances, up to a 90- day total supply. If your child is on a 4 to 6 month re-

check schedule, you will need to contact our office to request additional “Do Not Fill Until [date]”

prescriptions. These prescriptions will need to be picked-up at the office and may not be called into

your pharmacy per Federal regulation.

We suggest you contact our office when you notice your child has a 10 day supply of medication

remaining. This allows our providers adequate time to process your request prior to your child running

out of medication; we ask that you please plan accordingly. Also, please note that our providers’

schedules may vary, and we discourage same-day requests for prescriptions as your child’s provider may

be out of the office. If your child misses a re-check appointment and is out of medication, your child’s

providers may issue a 7 day prescription; you will be required to reschedule your child’s appointment

within seven days. Your child’s provider will not be able to write another prescription until your child

has a re-check appointment.

We appreciate your cooperation with these policies. Managing your child’s Schedule ll medications,

while complying with Federal and State regulations, can be a challenge for everyone involved. We

believe we can meet this challenge by working together as a team. Please feel free to call our office if

you have questions concerning these policies, of it you need to schedule a re-check appointment for

your child. We are dedicated to meeting your child’s healthcare needs and we thank you for choosing

Rose Pediatrics.

Patient Name:_______________________________________ Date of Birth:____________________

I have reviewed the ADD/ ADHD Medication Policy____________________________________________

Parent/Guardian Signature

Date:_________________________

General Information Form

This questionnaire will give you the opportunity to describe your concerns about your child. Your

answers will be kept strictly confidential. If you are not comfortable answering a question in writing,

please indicate and discuss these questions with your physician at the time of your visit.

Person Completing this Form:_____________________________________________________________

Relationship to Patient:__________________________________________________________________

What do you see as your child’s main problem(s)

At Home?

At School?

When were you first aware of these problems?

What are your child’s strengths? What is your child especially good at?

How does your child get along with the other children and siblings?

How have your child’s problems affected your family?

Why do you think your child acts like they do?

What types of things have you tried in order to help your child with his or her problems?

How do you usually discipline your child?

How consistent are you and your spouse with discipline?

What would you like to see change?

What are you wanting or expecting from this evaluation?

Anything else you think we should know or you would like to tell us?

Patient History Form

Pease fill out this form to the best of your abilities. Your answer will give us a better understanding of

your child’s problems. Your provider will go over your responses with you during your visit.

Medical History

Pregnancy and Birth History:

What was your child’s birth weight? __________________________

Did you deliver vaginally or c-section ? (Circle One)

How long was your pregnancy?_________________________ weeks

Did any of the following occur during your pregnancy?

Illnesses Smoking

Drug/Alcohol Use Caffeine Use

Slow Weight Gain Other Problems:_________________

Did you have any problems during labor or delivery? If yes, what?

Did your child have problems during or after birth? If yes, what?

Present Medical History:

When was your child’s last hearing and vision screening?

Hearing:__________________ Vision:__________________

Is your child on any medications? If yes, please list below.

Does your child have any allergies?

Has your child ever been hospitalized or had surgery? If yes, please list the age and the reason.

Has your child ever had any of the following? (Check all that apply)

Major Illnesses Other Major Injury Head Injury

Vision/Hearing Problems Mental Health Counseling Suspected Drug Use (Including glue or gas sniffing)

Frequent Ear Infections Frequent Stomach Pain Bedwetting/Stool Soiling

Unusual Ritualistic Behaviors Involuntary Muscle Movements Seizures

Clumsiness Frequent Headaches Breath-Holding Spells

Sleep Problems Physical or Sexual Abuse Anemia

Other Neurological Problems Head Banging or Other Nervous Habits

Are either parents involved in? (Check all that apply)

Lead Smelting Pottery or Tile Manufacturing Glazing Ceramics

Battery Manufacturing/Recycling Crafting Bullets or Fishing Wts Car Radiator Repair

Does your child eat dirt, paint chips, lint, etc. ? ________________________________________

Famiy History

Mother

Age:_________________________ Years of Schooling:________________________

Occupation:____________________________ Health Problems:_________________________

Had any miscarriages or stillborn babies?_____________________________________________

Father

Age:_________________________ Years of Schooling:________________________

Occupation:____________________________ Health Problems:_________________________

Are this child’s biological parents divorced? If yes, when?_______________________________

Please list names of full siblings (same mother and father) and ages:

Please list the names of all half siblings and ages:

Same Mother:

Same Father:

Who lives in your household now?

Any members of the family not in the house?

Has your family experienced any recent stresses, such as:

Deaths Financial Problems Serious Illnesses

Marital Problems Moves Divorce/Separation

Job Changes School Changes

Has anyone in either of the biologic parent families ever had any of the following? If so please

list their name and relationship to your child.

Trouble in School:____________________________________________________________

Problems with Attention:______________________________________________________

Mental Retardation/Slow Learner:_______________________________________________

Depression/Manic-Depression:__________________________________________________

Alcohol/Drug Problems:________________________________________________________

Other Mental Health Problems:__________________________________________________

Significant Health Problems:____________________________________________________

Legal Problems:______________________________________________________________

Physical or Sexual Abuse:______________________________________________________

School History

School_______________________________________ School Phone #____________________

Teacher______________________________________ Current Grade Level________________

What kind of grades is your child getting (Please Attach most recent report card)?

When were you first aware of problems with school?

Has your child ever needed any of the following ? (Check all that apply)

Special Education Special Tutoring Remedial Classes

Speech/Language Therapy To Repeat a Grade

Has your child ever had educational or psychological tests done?

If so when and by whom?_______________________________________________

Please attach a copy of the testing to this questionnaire if possible.

Does your child have difficulty with (mark all that apply):

Reading Printing/Handwriting Reversing Letters/Numbers

Math Copying Letters/Forms Expressing Themselves with Others

Spelling Pronouncing Words Understanding Verbal Instructions

Doing Tasks in the Right Order Getting written words in the Right Order

Developmental History

At what age did your child:

Sit by Themselves:________________________ Say Frist Word:___________________________

Crawl:__________________________________ Say Three Words:_________________________

Walk:__________________________________ Use 2 Word Phrases:______________________

Become Right/ Left Handed:________________ Use 3-4 Word Sentences:__________________

What was your child like as a:

Baby?

Toddler (18 mo – 3 yrs)?

Anything else that you think may be significant for us to know?

NICHQ Vanderbilt Assessment Scale – PARENT Informant*

Today’s Date: _________________ Child’s Name: ______________________________ Date of Birth:______________________

Parent’s Name: __________________________________________ Parent’s Phone Number:_____________________________

* Copyright 2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. Revised 1102

Symptoms Never Occasionally Often Very Often

1. Does not pay attention to details or makes careless mistakes with, for example, homework

0 1 2 3

2. Has difficulty keeping attention to what needs to be done 0 1 2 3

3. Does not seem to listen when spoken to directly 0 1 2 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

0 1 2 3

5. Has difficulty organizing tasks and activities 0 1 2 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 0 1 2 3

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) 0 1 2 3

8. Is easily distracted by noises or other stimuli 0 1 2 3

9. Is forgetful in daily activities 0 1 2 3

10. Fidgets with hands or feet or squirms in seat 0 1 2 3

11. Leaves seat when remaining seated is expected 0 1 2 3

12. Runs about or climbs too much when remaining seated is expected 0 1 2 3

13. Has difficulty playing or beginning quiet play activities 0 1 2 3

14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3

15. Talks too much 0 1 2 3

16. Blurts out answers before questions have been completed 0 1 2 3

17. Has difficulty waiting his or her turn 0 1 2 3

18. Interrupts or intrudes in on others’ conversations and/or activities 0 1 2 3

19. Argues with adults 0 1 2 3

20. Loses temper 0 1 2 3

21. Actively defies or refuses to go along with adults’ requests or rules 0 1 2 3

22. Deliberately annoys people 0 1 2 3

23. Blames others for his or her mistakes or misbehaviors 0 1 2 3

24. Is touchy or easily annoyed by others 0 1 2 3

25. Is angry or resentful 0 1 2 3

26. Is spiteful and wants to get even 0 1 2 3

27. Bullies, threatens, or intimidates others 0 1 2 3

28. Starts physical fights 0 1 2 3

29. Lies to get out of trouble or to avoid obligations (i.e. “cons” others) 0 1 2 3

30. Is truant from school (skips school) without permission 0 1 2 3

31. Is physically cruel to people 0 1 2 3

32. Has stolen things that have value 0 1 2 3

33. Deliberately destroys others’ property 0 1 2 3

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0 1 2 3

35. Is physically cruel to animals 0 1 2 3

36. Has deliberately set fires to cause damage 0 1 2 3

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.

Is this evaluation based on a time when the child was on medication was not on medication not sure?

NICHQVanderbiltParent.20050602

NICHQ Vanderbilt Assessment Scale – PARENT Informant*

Today’s Date: _________________ Child’s Name: ______________________________ Date of Birth:______________________

Parent’s Name: __________________________________________ Parent’s Phone Number:_____________________________

* Copyright 2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. Revised 1102

For Office Use Only

Total number of questions scored 2 or 3 in questions 1-9: ____________

Total number of questions scored 2 or 3 in questions 10-18: __________

Total Symptom Score for questions 1-18: _________________________





Average Performance Score: __________________________________

37. Has broken into someone else’s home, business, or car 0 1 2 3

38 Has stayed out at night without permission 0 1 2 3

39. Has run away from home overnight 0 1 2 3

40. Has forced someone into sexual activity 0 1 2 3

41. Is fearful, anxious, or worried 0 1 2 3

42. Is afraid to try new things for fear of making mistakes 0 1 2 3

43. Feels worthless or inferior 0 1 2 3

44. Blames self for problems, feels guilty 0 1 2 3

45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3

46. Is sad, unhappy, or depressed 0 1 2 3

47. Is self-conscious or easily embarrassed 0 1 2 3

Performance ExcellentAbove

Average Average

Somewhat of a

Problem Problematic

48. Overall school performance 1 2 3 4 5

49. Reading 1 2 3 4 5

50. Writing 1 2 3 4 5

51. Mathematics 1 2 3 4 5

52. Relationship with parents 1 2 3 4 5

53. Relationship with siblings 1 2 3 4 5

54. Relationship with peers 1 2 3 4 5

55 Participation in organized activities (e.g. teams) 1 2 3 4 5

Comments:


NICHQVanderbiltParent.20050602

HE0351

NICHQ Vanderbilt Assessment Scale—TEACHER Informant

Teacher’s Name: _______________________________ Class Time: ___________________ Class Name/Period: ________________

Today’s Date: ___________ Child’s Name: _______________________________ Grade Level: _______________________________

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are ratingand should reflect that child’s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: ___________.

Is this evaluation based on a time when the child � was on medication � was not on medication � not sure?


1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3

2. Has difficulty sustaining attention to tasks or activities 0 1 2 3

3. Does not seem to listen when spoken to directly 0 1 2 3

4. Does not follow through on instructions and fails to finish schoolwork 0 1 2 3(not due to oppositional behavior or failure to understand)

5. Has difficulty organizing tasks and activities 0 1 2 3

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained 0 1 2 3mental effort

7. Loses things necessary for tasks or activities (school assignments, 0 1 2 3pencils, or books)

8. Is easily distracted by extraneous stimuli 0 1 2 3

9. Is forgetful in daily activities 0 1 2 3

10. Fidgets with hands or feet or squirms in seat 0 1 2 3

11. Leaves seat in classroom or in other situations in which remaining 0 1 2 3seated is expected

12. Runs about or climbs excessively in situations in which remaining 0 1 2 3seated is expected

13. Has difficulty playing or engaging in leisure activities quietly 0 1 2 3

14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3

15. Talks excessively 0 1 2 3

16. Blurts out answers before questions have been completed 0 1 2 3

17. Has difficulty waiting in line 0 1 2 3

18. Interrupts or intrudes on others (eg, butts into conversations/games) 0 1 2 3

19. Loses temper 0 1 2 3

20. Actively defies or refuses to comply with adult’s requests or rules 0 1 2 3

21. Is angry or resentful 0 1 2 3

22. Is spiteful and vindictive 0 1 2 3

23. Bullies, threatens, or intimidates others 0 1 2 3

24. Initiates physical fights 0 1 2 3

25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others) 0 1 2 3

26. Is physically cruel to people 0 1 2 3

27. Has stolen items of nontrivial value 0 1 2 3

28. Deliberately destroys others’ property 0 1 2 3

29. Is fearful, anxious, or worried 0 1 2 3

30. Is self-conscious or easily embarrassed 0 1 2 3

31. Is afraid to try new things for fear of making mistakes 0 1 2 3

The recommendations in this publication do not indicate an exclusive course of treatmentor serve as a standard of medical care. Variations, taking into account individual circum-stances, may be appropriate.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’sHealthcare Quality

Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.

Revised - 0303

D4

D4 NICHQ Vanderbilt Assessment Scale—TEACHER Informant, continued

Teacher’s Name: _______________________________ Class Time: ___________________ Class Name/Period: _______________

Today’s Date: ___________ Child’s Name: _______________________________ Grade Level: ______________________________

Symptoms (continued) Never Occasionally Often Very Often

32. Feels worthless or inferior 0 1 2 3

33. Blames self for problems; feels guilty 0 1 2 3

34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3

35. Is sad, unhappy, or depressed 0 1 2 3

SomewhatPerformance Above of aAcademic Performance Excellent Average Average Problem Problematic

36. Reading 1 2 3 4 5

37. Mathematics 1 2 3 4 5

38. Written expression 1 2 3 4 5

SomewhatAbove of a

Classroom Behavioral Performance Excellent Average Average Problem Problematic

39. Relationship with peers 1 2 3 4 5

40. Following directions 1 2 3 4 5

41. Disrupting class 1 2 3 4 5

42. Assignment completion 1 2 3 4 5

43. Organizational skills 1 2 3 4 5

Comments:

Please return this form to: __________________________________________________________________________________

Mailing address: __________________________________________________________________________________________

________________________________________________________________________________________________________

Fax number: ____________________________________________________________________________________________

For Office Use Only

Total number of questions scored 2 or 3 in questions 1–9: __________________________

Total number of questions scored 2 or 3 in questions 10–18: ________________________

Total Symptom Score for questions 1–18: __________________________________________




Average Performance Score:______________________________________________

11-20/rev0303

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Dear Parents, - Rose Pediatrics