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Child & Youth Mental Health Algorithm - GPSC

Child & Youth Mental Health Algorithm - GPSC

Patient Name:Date of

Patient Name:Date of Birth:Physician Name:MRN/File No:Date:CADDRA ADHD ASSESSMENT FORMIdentifying InformationPatient: Date of Birth: Date seen:Age: Gender: m f Grade (actual/last completed):Current Occupation: student unemployed disability occupation:Status: child/adolescent OR adult single married common-law separated divorcedEthnic Origin: (check all that apply) Caucasian Asian Hispanic African-American NativeOther person providing collateral:Patient's phone no:DemographicsBiological Father (if known) Biological Mother (if known) Spouse/Partner (if applicable)NameOccupationHighest educationNumber of biological and/or half siblings:NameOccupationHighest educationNumber of step-siblings:Stepfather (if applicable) Stepmother (if applicable) Other Guardian (if applicable)Custody Time with bio Father Time with bio Mother Time with step family(circle custodial parent)Language At home: English Other ________________ At school _____________Children (if applicable) Number of biological: Number of step children:Names and ages________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CADDRA ADHD ASSESSMENT FORM 1/1287

Reason for ReferralReferred by: Phone: Fax:Initiated by: self parent spouse employer school physician other:Chief complaint: impulsiveness inattention hyperactivity(check all that apply) disorganization mood/anxiety procrastinationself esteem substance use academic problemsaggressionotherDetails:Attitude to referral:ADHD SYMPTOM HISTORY: (onset, progression, worsening factors, protective factors, adaptive strategies, outcome)88 Version: January 2011. Refer to www.caddra.ca for latest updates.CADDRA ADHD ASSESSMENT FORM 2/12

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