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General Practitioner-Vorlage

ADHD

Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
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Fachgebiet

General Practitioner

Genutzt

39 Zeiten

Art

Note

Zuletzt bearbeitet

11.8.2025

Erstellt von

Emily Goss

Vorlage verwenden

Über diese Vorlage

Looking for a streamlined way to document ADHD assessments? This ADHD template is perfect for General Practitioners and other healthcare professionals. It provides a structured framework to capture essential information, including past medical and psychiatric history, family history, medications, schooling, developmental milestones, and a detailed mental status examination. This template ensures comprehensive documentation, helping you to efficiently record all relevant details during patient consultations. When used with Heidi, the AI scribe, this template can be quickly populated from your clinical notes, saving you time and improving accuracy.

Vorlagenvorschau

Past Medical History Patient has a history of asthma, diagnosed at age 5. No other significant medical history. Past Psychiatric History including Suicidal Ideation Patient denies any past psychiatric history or suicidal ideation. Family History Father has a history of ADHD. Mother has a history of anxiety. No other significant family history. Medications Patient is currently taking methylphenidate 10mg twice daily. Schooling Patient is currently in year 9 and is struggling to keep up with school work. Developmental Patient met all developmental milestones on time. Forensic History Nil mentioned. Work History N/a Relationships Patient reports good relationships with family and friends. Sleep and appetite Patient reports difficulty falling asleep and decreased appetite. Milestones Patient met all developmental milestones on time. Mental Status Examination: - Appearance: Patient is well-groomed and dressed appropriately for the weather. - Behaviour: Patient is restless and fidgety during the consultation. - Speech: Speech is rapid and pressured. - Mood: Patient reports feeling frustrated and overwhelmed. - Affect: Affect is congruent with mood, but labile. - Thoughts: Patient reports racing thoughts and difficulty concentrating. - Perceptions: No hallucinations or sensory misinterpretations reported. - Cognition: Patient is oriented to person, place, and time. Concentration is impaired. Memory intact. - Insight: Patient acknowledges difficulties with attention and hyperactivity. - Judgment: Judgment appears intact.

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