Adhd questionaire

ADHD Questionnaire
What symptoms has your child shown that make you concerned about attention deficit/hyperactivity disorder?
What interventions/medications have you tried with your child?
What medication(s) is your child taking? (Include nonprescription drugs and herbal supplements)
Does your child have a history of any of the following? (Circle yes or no)
Physician Notes
• Fainting or dizziness (particularly with exercise) • Chest pain or shortness of breath with exercise • Unexplained change in exercise tolerance • Sensation of increased heart rate, extra • Heart murmur other than an innocent murmur • Viral illness with chest pain or palpitations Has anyone in the family had any of the following? (Circle yes or no)
• Sudden or unexplained death in someone young • Heart attack at younger than 35 years old • Hypertrophic cardiomyopathy or other dilated • Event requiring resuscitation in young members (<35 years old), including syncope (passing out) requiring resuscitation Completed by:_________________________ ______________________
Relationship to Patient
Date: ________________________________
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ADHD Medication Precaution
General Possible Side Effects of ADHD Drugs
The common side effects of stimulant medications include decreased appetite, trouble sleeping, mood swings, stomachaches, and headaches. For certain children with medical conditions listed below, there may be an increased risk of more severe problems. In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides that contain information about the risks associated with the medications. The guides must alert patients that the medications may lead to possible cardiovascular (heart and blood) or psychiatric problems. The agency undertook this precaution when a review of data found that ADHD patients with existing heart conditions had a slightly higher risk of strokes, heart attacks, and/or sudden death when taking the medications. The review also found a slight increased risk, about 1 in 1,000, for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic (an overly high mood), even in patients without a history of psychiatric problems. The FDA recommends that any treatment plan for ADHD include an initial health history, including family history, and examination for existing cardiovascular and psychiatric problems. One ADHD medication, the non-stimulant atomoxetine (Strattera), carries another warning. Studies show that children
and teenagers who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD
who do not take it. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop
serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other
people who spend a lot of time with your child to tell you if they notice changes in your child's behavior. Call a doctor
right away if your child shows any unusual behavior. While taking atomoxetine, your child should see a doctor often,
especially at the beginning of treatment, and be sure that your child keeps all appointments with his or her doctor.

If your child is started on a medication for ADHD, it is recommended that personal and family history, blood pressure,
pulse, height, and weight be reviewed on a regular basis, as often as every 1-6 months. Side effects and efficacy should
also be reviewed on a regular basis. Your doctor may request an ECG (heart rhythm test) be ordered before starting
medication or with medication dose changes.
Many of the medications that treat ADHD are controlled substances, meaning the provider can only give you a 1-3
month prescription at a time, and they must be picked up in person or mailed to your home.
WE CANNOT CALL THEM INTO THE PHARMACY for you.

Reference: Vetter et al. Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Medications for Attention Deficit/Hyperactivity
Disorder: A Scientific Statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects
Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117;2407-2423.
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Source: http://www.saintalskids.com/images/website275/adhd_questionaire4_mar09_1.pdf