2 years ago

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:Medical HistoryAllergies: No Yes (Details):Cardiovascular medical history:hypertension tachycardia arrhythmia dyspnoea fainting chest pain on exertion otherSpecific cardiovascular risk identified: No Yes (Details):Positive lab or EKG findings:Positive medical history: In utero exposure to Stigmata of FAS/FAE History of anoxia/perinatalnicotine, alcohol or drugscomplicationsDevelopmental delays Coordination problems Cerebral palsy Lead poisoningNeurofibromatosis Myotonic dystrophy Other genetic syndrome Hearing/visual problemsThyroid disorder Diabetes Growth delay AnemiaTraumatic brain injury Seizures Enuresis InjuriesSleep apnea Tourette's/tics Enlarged adenoids or tonsils AsthmaSleep disorders Secondary symptoms Medical complications of drug/alcohol useto medical causesOther/details:Medication HistoryExtended health insurance: No Yes (Details):Public Private insurance Coverage for psychological treatment: No YesAdherence to treatment/attitude towards medication:Difficulty swallowing pills: No Yes(If applicable) Contraception: No Yes (Details):Current medications Dose Duration Rx Outcome and side effectsPrevious medications Dose Duration Rx Outcome and side effectsCADDRA ADHD ASSESSMENT FORM 3/1289

Patient Name:Date of Birth:Physician Name:MRN/File No:Date:Physical ExaminationPractice guidelines around the world recognize the necessity of a physical exam as part of an assessment for ADHD in order to rule out organiccauses of ADHD, rule out somatic sequelae of ADHD, and rule out contraindications to medications. While this physical exam follows all the usualprocedures, several specific evaluations are required. These include, but are not limited to:Rule out medical causes of ADHD-like symptoms1. Hearing and vision assessment2. Thyroid disease3. Neurofibromatosis (cafe au lait spots)4. Any potential cause of anoxia (asthma, CF, cardiovascular disease)5. Genetic syndromes and facial or dysmorphic characteristics6. Fetal alcohol syndrome: growth retardation, small head circumference,smaller eye openings, flattened cheekbones and indistinctphiltrum (underdeveloped groove between nose and upper lip)7. Physical abuse: unset fractures, burn marks, unexplained injuries8. Sleep disorders: enlarged tonsils and adenoids, difficultybreathing, sleep apnea9. Growth delay or failure to thrive10. PKU, heart disease, epilepsy and unstable diabetes can all beassociated with attention problems11. Head trauma.Date of last physical exam:Medical history/lab work provides information on maternal drinking inpregnancy, sleep apnea, failure to thrive, lead poisoning, traumatic brain injury.Rule out sequelae of ADHD1. Abuse2. High pain threshold3. Irregular sleep, delayed sleep phase, short sleep cycle4. Comorbid developmental coordination disorder, evidenced by motordifficulties in doing routine tasks such as getting on the exam table5. Picky eater: will not sit to eat6. Evidence of injuries from poor coordination or engagement inextreme sportsRule out contraindications to medication:1. Glaucoma2. Uncontrolled hypertension3. Any evidence of significant cardiovascular abnormalityBy who:Abnormal findings last exam:Current Physical ExamSystem Done Normal Findings (Details of Abnormality)No Yes No YesSkinENTRespiratoryGI and GUCerebrovascularMusculoskeletalImmunol. & HematologicalNeurologicalEndocrinologicalDysmorphic facial featuresOtherWeight: Height: Head Circum: BP: Pulse:In children: percentile In children: percentile (In children only)Positive Findings on Observation: (Details)90 Version: January 2011. Refer to for latest updates.CADDRA ADHD ASSESSMENT FORM 4/12

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