Initial Adult ADHD Assessment Notes

Identifying Information: Patient's Name: [Full name of the patient as provided] (include only if explicitly mentioned) Date of Birth: [Patient's date of birth] (include only if explicitly mentioned) Gender: [Gender of the patient, e.g., male, female, non-binary] (include only if explicitly mentioned) Date of Assessment: [Date when the assessment was conducted] (include only if explicitly mentioned) Reason for Assessment: [describe the reason the patient is seeking an ADHD assessment] (only include describe the reason the patient is seeking an ADHD assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Mental State Examination: appearance and behaviour - [describe the patient’s appearance and behaviour during the interview] (only include describe the patient’s appearance and behaviour during the interview if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) speech patterns - [describe the patient’s speech patterns] (only include describe the patient’s speech patterns if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) mood and affect - [describe the patient’s mood and affect] (only include describe the patient’s mood and affect if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) thought processes - [describe the patient’s thought processes] (only include describe the patient’s thought processes if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) attention and concentration during the interview - [describe the patient’s attention and concentration during the interview] (only include describe the patient’s attention and concentration during the interview if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) level of insight into their difficulties - [describe the patient’s level of insight into their difficulties] (only include describe the patient’s level of insight into their difficulties if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Patient History: developmental history - [document developmental history including pregnancy, birth, milestones, and childhood behavioural concerns] (only include document developmental history including pregnancy, birth, milestones, and childhood behavioural concerns if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) family history of ADHD or other psychiatric conditions - [document family history of ADHD or other psychiatric conditions in first-degree relatives] (only include document family history of ADHD or other psychiatric conditions in first-degree relatives if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) past and current medical conditions - [document past and current medical conditions including head injuries, sleep disorders, medications, and other differentials] (only include document past and current medical conditions including head injuries, sleep disorders, medications, and other differentials if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) educational history - [document educational history including academic performance, behavioural issues, supports, and discrepancies between ability and achievement] (only include document educational history including academic performance, behavioural issues, supports, and discrepancies between ability and achievement if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) employment history - [document employment history including job stability, performance feedback, and task-related difficulties] (only include document employment history including job stability, performance feedback, and task-related difficulties if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) current and past substance use - [document current and past substance use, especially in relation to self-medication] (only include document current and past substance use, especially in relation to self-medication if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) previous psychiatric diagnoses - [document previous psychiatric diagnoses, treatments, and response to interventions] (only include document previous psychiatric diagnoses, treatments, and response to interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Inattention: any issues with attention to detail - [describe any issues with attention to detail or careless mistakes in significant activities] (only include describe any issues with attention to detail or careless mistakes in significant activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) any difficulties sustaining attention - [describe any difficulties sustaining attention in tasks, whether work or leisure] (only include describe any difficulties sustaining attention in tasks, whether work or leisure if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) active listening - [describe whether patient seems not to listen when spoken to directly] (only include describe whether patient seems not to listen when spoken to directly if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) issues following instructions - [describe issues following instructions or completing important tasks] (only include describe issues following instructions or completing important tasks if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) difficulties organising tasks - [describe difficulties organising tasks and activities] (only include describe difficulties organising tasks and activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) any avoidance or reluctance to undertake tasks - [describe any avoidance or reluctance to undertake tasks requiring sustained mental effort] (only include describe any avoidance or reluctance to undertake tasks requiring sustained mental effort if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) any tendency to lose items - [describe any tendency to lose items necessary for tasks and activities] (only include describe any tendency to lose items necessary for tasks and activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) distractions: [describe frequency and nature of distractions] (only include describe frequency and nature of distractions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) forgetfulness - [describe forgetfulness in day-to-day activities] (only include describe forgetfulness in day-to-day activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Hyperactivity: fidgeting or squirming - [describe presence of fidgeting, tapping, or squirming] (only include describe presence of fidgeting, tapping, or squirming if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) leaving seat - [describe any leaving seat inappropriately in settings where remaining seated is expected] (only include describe any leaving seat inappropriately in settings where remaining seated is expected if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) restlessness - [describe feelings of internal restlessness that are hard to control] (only include describe feelings of internal restlessness that are hard to control if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) difficulty with quiet activities - [describe difficulty engaging in quiet social or leisure activities] (only include describe difficulty engaging in quiet social or leisure activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) feeling “on the go” - [describe sense of being “on the go” or “driven by a motor”] (only include describe sense of being “on the go” or “driven by a motor” if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) talking excessively - [describe excessive talking] (only include describe excessive talking if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Impulsivity: blurting answers - [describe any tendency to blurt out answers before questions are completed] (only include describe any tendency to blurt out answers before questions are completed if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) waiting turn - [describe difficulties waiting turns] (only include describe difficulties waiting turns if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) interrupting or intruding - [describe instances of interrupting or intruding on others] (only include describe instances of interrupting or intruding on others if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Symptom Severity & Diagnostic Prompts: symptom tallies - [describe the number of inattentive and hyperactive-impulsive symptoms identified] (only include describe the number of inattentive and hyperactive-impulsive symptoms identified if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) functional impairment - [describe the severity of impairment across social, academic, occupational, and home functioning] (only include describe the severity of impairment across social, academic, occupational, and home functioning if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) age of onset - [confirm whether symptoms were present before age 12] (only include confirm whether symptoms were present before age 12 if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) differential diagnosis - [confirm that symptoms are not better explained by another psychiatric or medical condition or substance use] (only include confirm that symptoms are not better explained by another psychiatric or medical condition or substance use if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) final diagnostic impressions - [document clinician’s final diagnostic impressions and conclusions] (only include document clinician’s final diagnostic impressions and conclusions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)