ADHD follow-up
Behavioral health

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

INTERVAL HISTORY
Patient and parent or caregiver present: [ ]
Function at school, work and home as reported: [ ]
Rating scales used, who completed them and scores: [ ]

MEDICATION
Medication and dose as reported, timing and adherence: [ ]
Benefit and duration of effect as reported: [ ]
Appetite, sleep, mood and other adverse effects as reported: [ ]
Prescription monitoring program checked and findings, if applicable: [ ]

FINDINGS
Weight, blood pressure and heart rate measured today, with units: [ ]
Other examination findings: [ ]

ASSESSMENT AND PLAN
Current status and reasoning: [ ]
Medication decisions and rationale: [ ]
Behavioral or school supports discussed: [ ]
Prescription and monitoring plan: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]