I am writing to you regarding my patient, John Smith, who presented to my clinic on 1 November 2024.
John presented today for a review of his ADHD symptoms and to discuss potential treatment options. He reports ongoing difficulties with focus, organisation, and impulsivity, impacting his work and personal life.
John reports that his difficulties with focus, organisation, and impulsivity started in childhood. He recalls struggling with schoolwork, losing items, and difficulty following instructions. These challenges persisted into adulthood.
John reports experiencing emotional dysregulation, including mood swings and frustration, particularly when faced with tasks requiring sustained attention.
John has no past psychiatric history.
John has no forensic history.
Medical History:
* Current Health: Generally good health.
* Chronic Medical Conditions: Nil.
* Neurological Issues: Nil.
* Medications:
* Prescribed: None.
* Over-the-counter: Occasional paracetamol for headaches.
* Supplements: None.
* Allergies: No known allergies.
Mental Health:
* Current and history of mental state: John reports feeling anxious and overwhelmed at times. He has a history of low mood, but no current symptoms of depression.
* Previous mental health diagnoses: None.
* Psychiatric treatments and outcomes: None.
Developmental History:
* Pregnancy and birth complications: No complications.
* Early developmental milestones: Met milestones appropriately.
* School experiences: Struggled with focus and organisation in school. Repeated a year in primary school.
* Social and peer relationships: Had difficulty making and maintaining friendships.
Family History:
* Mental health conditions: Father diagnosed with ADHD.
* Neurodevelopmental conditions: None.
* Family dynamics: Good relationship with parents and siblings.
Educational and Occupational History:
* Highest level of education: Completed secondary school.
* Employment history: Worked in various part-time jobs.
* Current employment status: Unemployed.
Psychosocial History:
* Living arrangements: Lives with parents.
* Support network: Limited support network.
* Relationship history: No current romantic relationships.
Substance Misuse History:
* Alcohol use: Occasional social drinking.
* Recreational drug use: None.
* Tobacco use: Smokes occasionally.
ADHD-specific symptoms:
* Inattention section:
* Difficulty focusing on tasks.
* Easily distracted.
* Poor organisational skills.
* Hyperactivity & impulsivity:
* Restlessness.
* Impulsive decision-making.
ADHD impact on life:
* Education: Struggled in school.
* Employment: Difficulty maintaining employment.
* Emotional health: Experiences anxiety and low mood.
* Finances: Struggles with managing finances.
* Friendships: Difficulty maintaining friendships.
* Leisure time/relaxation/sleep: Difficulty relaxing and sleeping.
PART 2: DIAGNOSIS AND FORMULATION
Summary of the DIVA-5 outcome measure
A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development – characterised by deficits in social communication and social interaction across multiple contexts, as manifested by, all the following, currently or by history:
A1 - Symptoms of Inattention:
- A1(a): Do you often fail to give close attention to details, or do you make careless mistakes in your work or during other activities? And how was that during childhood (in schoolwork or during other activities)? Adult: present, Child: present
- A1(b): Do you often have difficulty sustaining your attention in tasks? And how was that during childhood (in play activities)? Adult: present, Child: present
- A1(c): Does it often seem as though you are not listening when you are spoken to directly? And how was that during childhood? Adult: present, Child: present
- A1(d): Do you often not follow through on instructions and often fail to finish chores or duties in the workplace? And how was that during childhood (in schoolwork)? Adult: present, Child: present
- A1(e): Do you often find it difficult to organise tasks and activities? And how was that during childhood? Adult: present, Child: present
- A1(f): Do you often avoid (or do you dislike, or are you reluctant to engage in) tasks that require sustained mental effort? And how was that during childhood? Adult: present, Child: present
- A1(g): Do you often lose things that are necessary for tasks or activities? And how was that during childhood? Adult: present, Child: present
- A1(h): Are you often easily distracted by extraneous stimuli? And how was that during childhood? Adult: present, Child: present
- A1(i): Are you often forgetful in daily activities? And how was that during childhood? Adult: present, Child: present
Total number of criteria met for Attention Deficit: Adult: 9/9, Child: 9/9
A2 - Symptoms of Hyperactivity and Impulsivity:
- A2(a): Do you often fidget with or tap hands or feet, or do you often squirm in your seat? And how was that during childhood? Adult: present, Child: present
- A2(b): Do you often leave your seat in situations where it is expected that you remain seated? And how was that during childhood? Adult: not present, Child: present
- A2(c): Do you often feel restless? And how was that during childhood? Adult: present, Child: present
- A2(d): Do you often find it difficult to engage in leisure activities quietly? And how was that during childhood (in play activities)? Adult: present, Child: present
- A2(e): Are you often “on the go” or do you often act as if “driven by a motor”? And how was that during childhood? Adult: present, Child: present
- A2(f): Do you often talk excessively? And how was that during childhood? Adult: present, Child: present
- A2(g): Do you often blurt out an answer before questions have been completed? And how was that during childhood? Adult: present, Child: present
- A2(h): Do you often find it difficult to await your turn? And how was that during childhood? Adult: present, Child: present
- A2(i): Do you often interrupt or intrude on others? And how was that during childhood? Adult: present, Child: present
Total number of criteria met for Hyperactivity/Impulsivity: Adult: 9/9, Child: 9/9
B. Several inattentive or hyperactive-impulsive symptoms were present prior to the age of 12 years: Yes (Patient reported symptoms of ADHD before the age of 12, based on clinical history, self-report, and collateral information.)
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more areas: Yes (Symptoms are observed across multiple settings, such as work, school, social relationships, and personal life.)
- Work/Education: Struggles with completing tasks and maintaining focus.
- Relationships and Family: Difficulty with household responsibilities.
- Social Contacts: Struggles with making and maintaining friendships.
- Free Time/Hobbies: Finds it difficult to relax and complete leisure activities.
- Self-Confidence and Self-Image: Experiences low self-esteem.
D. There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning: Yes (ADHD symptoms cause significant impairment in daily life across social, academic, and occupational domains.)
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal): Yes (Symptoms are best attributed to ADHD rather than another psychiatric or medical condition.)
A) Inattention
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
- John reports making careless mistakes at work.
2) Often has difficulty sustaining attention in tasks or play activities
- John reports difficulty sustaining attention in tasks.
3) Often does not seem to listen when spoken to directly
- John reports not listening when spoken to directly.
4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- John reports not following through on instructions.
5) Often has difficulty organizing tasks and activities
- John reports difficulty organizing tasks and activities.
6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
- John reports avoiding tasks that require sustained mental effort.
7) Often loses things necessary for tasks or activities
- John reports losing things necessary for tasks or activities.
8) Is often easily distracted by extraneous stimuli
- John reports being easily distracted by extraneous stimuli.
9) Is often forgetful in daily activities
- John reports being forgetful in daily activities.
B) Hyperactivity and Impulsivity
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fidgets with or taps hands or feet or squirms in seat
- John reports fidgeting with hands and feet.
2) Often leaves seat in situations when remaining seated is expected
- John reports leaving his seat in situations where remaining seated is expected.
3) Often runs about or climbs in situations where it is inappropriate
- No information provided.
4) Often unable to play or engage in leisure activities quietly
- John reports difficulty engaging in leisure activities quietly.
5) Is often “on the go,” acting as if “driven by a motor”
- John reports feeling "on the go".
6) Often talks excessively
- John reports talking excessively.
7) Often blurts out an answer before a question has been completed
- John reports blurting out answers.
8) Often has difficulty waiting his or her turn
- John reports difficulty waiting his turn.
9) Often interrupts or intrudes on others
- John reports interrupting others.
Symptoms interfere with or reduce the quality of:
- Social Functioning: Difficulty maintaining friendships.
- Academic Functioning: Struggles with completing tasks and maintaining focus.
- Occupational Functioning: Difficulty maintaining employment.
- Home Functioning: Difficulty with household responsibilities.
I am writing to you regarding my patient, [Patient's Name], who presented to my clinic on [Date of Visit].
[describe presenting difficulties, reasons for visit, discussion topic] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe history of presenting difficulties] (write in full sentences) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe emotional regulation] (write in full sentences) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe past psychiatric history] (write in full sentences) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe forensic history] (write in full sentences) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe medical history] (include the following as sub-headings and describe them in full sentences: current health, chronic medical conditions, neurological issues, medications (in subcategories: prescribed, over-the-counter, supplements), allergies) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe mental health] (include the following as sub-headings and describe them in full sentences: current and history of mental state, previous mental health diagnoses, psychiatric treatments and outcomes) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe development history] (include the following as sub-headings and describe them in full sentences: pregnancy and birth complications, early developmental milestones, school experiences, social and peer relationships) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe family history] (include the following as sub-headings and describe them in full sentences: mental health conditions, neurodevelopmental conditions, family dynamics) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe educational and occupational history] (include the following as sub-headings and describe them in full sentences: highest level of education, employment history, current employment status) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe psychosocial history] (include the following as sub-headings and describe them in full sentences: living arrangements, support network, relationship history) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe substance misuse history] (include the following as sub-headings and describe them in full sentences: alcohol use, recreational drug use, tobacco use) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe ADHD-specific symptoms] (include the following as sub-headings and describe them in full sentences and in a lot of detail: inattention section, hyperactivity & impulsivity) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe ADHD impact on life] (include the following as sub-headings and describe them in full sentences: education, employment, emotional health, finances, friendships, leisure time/relaxation/sleep) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PART 2: DIAGNOSIS AND FORMULATION
Summary of the DIVA-5 outcome measure
A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development – characterised by deficits in social communication and social interaction across multiple contexts, as manifested by, all the following, currently or by history:
A1 - Symptoms of Inattention:
- A1(a): Do you often fail to give close attention to details, or do you make careless mistakes in your work or during other activities? And how was that during childhood (in schoolwork or during other activities)? Adult: [present/not present], Child: [present/not present]
- A1(b): Do you often have difficulty sustaining your attention in tasks? And how was that during childhood (in play activities)? Adult: [present/not present], Child: [present/not present]
- A1(c): Does it often seem as though you are not listening when you are spoken to directly? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A1(d): Do you often not follow through on instructions and often fail to finish chores or duties in the workplace? And how was that during childhood (in schoolwork)? Adult: [present/not present], Child: [present/not present]
- A1(e): Do you often find it difficult to organise tasks and activities? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A1(f): Do you often avoid (or do you dislike, or are you reluctant to engage in) tasks that require sustained mental effort? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A1(g): Do you often lose things that are necessary for tasks or activities? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A1(h): Are you often easily distracted by extraneous stimuli? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A1(i): Are you often forgetful in daily activities? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
Total number of criteria met for Attention Deficit: Adult: [X/9], Child: [X/9]
A2 - Symptoms of Hyperactivity and Impulsivity:
- A2(a): Do you often fidget with or tap hands or feet, or do you often squirm in your seat? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(b): Do you often leave your seat in situations where it is expected that you remain seated? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(c): Do you often feel restless? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(d): Do you often find it difficult to engage in leisure activities quietly? And how was that during childhood (in play activities)? Adult: [present/not present], Child: [present/not present]
- A2(e): Are you often “on the go” or do you often act as if “driven by a motor”? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(f): Do you often talk excessively? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(g): Do you often blurt out an answer before questions have been completed? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(h): Do you often find it difficult to await your turn? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
- A2(i): Do you often interrupt or intrude on others? And how was that during childhood? Adult: [present/not present], Child: [present/not present]
Total number of criteria met for Hyperactivity/Impulsivity: Adult: [X/9], Child: [X/9]
B. Several inattentive or hyperactive-impulsive symptoms were present prior to the age of 12 years: [Yes/No] (Indicate whether the patient exhibited symptoms of ADHD before the age of 12, based on clinical history, self-report, or collateral information. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more areas: [Yes/No] (State whether symptoms are observed across multiple settings, such as work, school, social relationships, and personal life. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Work/Education: [Describe difficulties in workplace or academic settings] (Summarize whether the patient has struggled with administrative tasks, planning, completing homework, or maintaining focus in professional or educational environments. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Relationships and Family: [Describe challenges in relationships] (State whether the patient has difficulties with household responsibilities, maintaining romantic relationships, or required prolonged parental structure. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Social Contacts: [Describe social difficulties] (Summarize whether the patient struggles with making and maintaining friendships, experiences social fatigue, or exhibits low self-assertiveness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Free Time/Hobbies: [Describe engagement in leisure activities] (Indicate whether the patient finds it difficult to relax, struggles to complete leisure activities such as reading or watching films, or tires quickly of hobbies. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Self-Confidence and Self-Image: [Describe self-perception and emotional responses] (State whether the patient experiences low self-esteem, fear of failure, perfectionism, or excessive sensitivity to criticism, and whether these difficulties were also present in childhood. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
D. There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning: [Yes/No] (Specify whether ADHD symptoms cause significant impairment in daily life across social, academic, or occupational domains. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal): [Yes/No] (Confirm whether symptoms are best attributed to ADHD rather than another psychiatric or medical condition. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
A) Inattention
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2) Often has difficulty sustaining attention in tasks or play activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3) Often does not seem to listen when spoken to directly
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5) Often has difficulty organizing tasks and activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7) Often loses things necessary for tasks or activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8) Is often easily distracted by extraneous stimuli
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
9) Is often forgetful in daily activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
B) Hyperactivity and Impulsivity
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fidgets with or taps hands or feet or squirms in seat
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2) Often leaves seat in situations when remaining seated is expected
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3) Often runs about or climbs in situations where it is inappropriate
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4) Often unable to play or engage in leisure activities quietly
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5) Is often “on the go,” acting as if “driven by a motor”
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6) Often talks excessively
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7) Often blurts out an answer before a question has been completed
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8) Often has difficulty waiting his or her turn
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
9) Often interrupts or intrudes on others
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Symptoms interfere with or reduce the quality of:
- Social Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include observations related to social impairments) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Academic Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include observations related to academic challenges) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Occupational Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include if occupational functioning is impacted) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Home Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (focus on impairments or distress in the home environment) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
