Registration for ADHD Center of Connecticut

Thank you for taking the time to fill in the information requested on this form. By doing this, you will make it easier for us to get to know your child and his/her needs as well as formulate a treatment plan. If you are not sure of an answer, leave blank and we can discuss at the initial evaluation meeting.
Patient's Name

First Name Last Name
Patient's Date of Birth

Month Day Year
Patient's School Grade
Hand used for writing

Right Hand Left Hand
Eyeglasses?:

Yes No
If yes reason for glasses:
Date of last vision screen:
Parent /Guardian's Name *

First Name Last Name
Parent /Guardian's Email *
Parent /Guardian's preferred contact number *

Area Code Phone Number
Parent/Guardian's Occupation
Where does patient currently get their ADHD care/management?

The Center for Advanced Pediatrics Other Pediatrician or Doctor/Center (ei. Psychiatrist, Therapist) Never been treated for ADHD
Referring Physician's Name (For Non-TCFAP Patients)
Referring Physician's Phone # (For Non-TCFAP Patients)

Area Code Phone Number
Referring Physician's Fax # (if known)

Area Code Phone Number
Referring Physician's address (For Non-TCFAP Patients)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Language (s) spoken in the home:
Birth History
Was your child adopted?

Yes No
If Yes, where was your child born?
If yes, how old was your child when he/she was placed in your care?
Medications taken during pregnancy
Born on time?

Yes Premature (enter #weeks below)
# of weeks of pregnancy when patient born:
Delivery type:

Vaginal Cesarean (enter reason below)
Reason for Cesarean:
Birth Weight
Birth Length
Pregnancy/Birth/Post Birth complications? (jaundice, NICU etc.) Please explain:
Did any previous pregnancy result in a miscarriage?

Yes No
Communicaton (Receptive and Expresive Language):
Does your child have a speech or language problem?

Yes No
If yes, please describe:
When was the problem first noticed and by whom?
At what age was your child easily understood by others?
How does your child communicate?

Gestures Single Words Short Phrases Sentences Sign Language Other
Has your child seen a speech or language specialist. If yes, name and date (s) of test and results:
Has your child had an Audiological Exam (Hearing Test)? If yes, please give date of test and results:
How does your child respond to sound (voices or noises):
Developmental & Social History

Please answer when child met developmental milestones and describe issues with school and behavior.
Rolled over for the first time (around 3-4 months)

On time Late
Sat up well (around 6-8 months)

On time Late
Walked alone (10-16 months)

On time Late
Talked (2 words) (18-24 months)

On time Late
Toilet trained (2-3 yrs old)

On time Late
Diet Problems:
Sleep Problems
At what age was your child easily understood by others?
Does your child often need to have things repeated to understand them?

Yes No
Does your child have difficulty following directions?

Yes No
Can your chiild remember a short message?

Yes No
Medical History
Hospitalizations
Surgeries
Allergies to meds and/or other
Is Patient currently on ADHD Medications?

Yes No No, but has been in the past
Current Medications
Past Medications taken for MORE THAN 2 WEEKS
Are immunizations up to date for age?

Yes No No, but working towards No, we have declined vaccinations
Vaccinations missed or refused:
If female, have menstrual cycles begun?

Yes No Yes, but cycles irregular
Age menstrual periods begun:
Last menstrual period began (how many days ago)
Any concerns about menstruation?
Any other health problems?
Current Behaviors
Please check any of the following items that relate to your child's current behavior(s):

Shy Immature Well behaved Stubborn Impulsive Temper tantrums Cries excessively Tells lies Thumb sucking Head banging Nail biting More active than others Clumsy using hands Poor handwriting Clumsy walking Blank spells or Fainting Spells Noise or Touch Sensitivity Tics and Twitching Always in motion Excessively fidgety Difficulty paying attention Difficulty staying at one task for a long time Gets distracted while watching TV Difficulty with transitions Difficulty with finishing a task Disorganized Shows poor judgement in dangerous or questionable situations Poor awareness of time Gets lost easily' Frequent accounts Destructive/Aggressiveness Difficulty listening Gets easily frustrated Has poor self-esteem Fears making mistakes Eats paper, paints, etc. Moods change quickly Difficulty understanding jokes Self abusive behavior Withdrawn Stubborn Plays alone for a reasonable length of time Poor eye contact Cooperative Attentive Willing to try new activities
Family History
Names, ages, gender of household members and family living in the home:
Names, ages, gender of household members and family living outside the home:
Who is the child's primary caregiver?
Who cares for the child when the primary caregiver is away?
Family Relations
Are there significant marital conflicts?

Yes No
If yes, describe briefly:
Is there conflict between child and parent?

Yes No
If yes, describe briefly:
Is there conflict between siblings?

Yes No
If yes, describe briefly:
Do parents agree on discipline?

Yes No
Who usually disciplines the child and how?
Does your child have difficulty getting along with adults?

Yes No
Does your child have difficulty getting along with siblings?

Yes No
Describe your child's relationship with his/her siblings:
Educational History
When did your child first start attending school (age):
What, if any, problems were reported at school?
List all prior schools attended and years of attendance:
Current school attending and grade placement:
Current teacher's name(s):
Has your child ever been held back a grade? If so, which grade(s)
Has your child ever been suspended from school? if so, how many times and when.
Special Ed/Placements (Include age placed in Special Education)
Please describe any private support/services your child receives:
What are your child's strengths and/or best subjects?
Is your child having difficulty with any subjects?
Describe your child's attitude towards school:
Has your child ever missed an extended amount of school? If yes, please explain:
Social Emotional Development
Describe your child's current social skills and peer relationships. Please note if your child has a history of being bullied/teased or has been aggressive in play with others.
How would you describe your child socially? How do you think your child interacts with peers while at school?
Does your child have a best friend?

Yes No
Please list your child's favorite hobbies, activities, games and other sports (ei. piano, books, dolls, crafts, etc. ) Also please describe how well you feel your child does in those areas.
Please list any additional organizations, clubs, teams or groups in which your child participates other than sports:
How does your child handle stress?
What are your child's strengths?
In what areas would you like to see your child stronger?
What are your goals for treatment?

Birth History

Developmental & Social History

Medical History

Current Behaviors

Family History

Family Relations

Educational History

Social Emotional Development