Evaluation for ADHD Template

MSE:  
- Behaviour: The patient appeared restless and frequently shifted in their seat during the session. They also interrupted the psychologist multiple times.  
- Mood: The patient reported feeling frustrated and overwhelmed. The psychologist observed signs of irritability.  
- Thoughts: The patient's thoughts were coherent and oriented to time and place.  
- Cognition: No concerns reported or observed.  
Observations:  
- The patient frequently tapped their foot and seemed distracted by noises outside the room.  
Reason for assessment:  
- The patient was referred for an ADHD assessment due to ongoing difficulties with attention and impulsivity impacting their academic performance.  
Background:  
- Family members: Lives with both parents and a younger sibling.  
- Family history: The patient's father has a history of ADHD.  
- School and Year level: Attends Greenfield High School, currently in Year 9.  
- Pregnancy and Birth History: No significant concerns reported.  
- Childhood History: Experienced frequent ear infections as a child.  
A) Inattention  
1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities  
- The patient often makes careless mistakes in math assignments.  
2) Often has difficulty sustaining attention in tasks or play activities  
- The patient struggles to maintain focus during class lectures.  
3) Often does not seem to listen when spoken to directly  
- The patient frequently needs instructions repeated.  
4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace  
- The patient often leaves homework incomplete.  
5) Often has difficulty organizing tasks and activities  
- The patient struggles with organizing their school backpack.  
6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort  
- The patient avoids reading assignments.  
7) Often loses things necessary for tasks or activities  
- The patient frequently misplaces school supplies.  
8) Is often easily distracted by extraneous stimuli  
- The patient is easily distracted by classroom noises.  
9) Is often forgetful in daily activities  
- The patient often forgets to bring necessary materials to class.  
B) Hyperactivity and Impulsivity  
1) Often fidgets with or taps hands or feet or squirms in seat  
- The patient frequently taps their foot during class.  
2) Often leaves seat in situations when remaining seated is expected  
- The patient often gets up during class without permission.  
3) Often runs about or climbs in situations where it is inappropriate  
- Not observed.  
4) Often unable to play or engage in leisure activities quietly  
- The patient is loud during group activities.  
5) Is often “on the go,” acting as if “driven by a motor”  
- The patient is described as always being on the move by teachers.  
6) Often talks excessively  
- The patient talks excessively during class.  
7) Often blurts out an answer before a question has been completed  
- The patient frequently interrupts the teacher with answers.  
8) Often has difficulty waiting his or her turn  
- The patient struggles to wait their turn in games.  
9) Often interrupts or intrudes on others  
- The patient often interrupts peers during conversations.  
Symptoms interfere with or reduce the quality of:  
- Social Functioning: The patient has difficulty maintaining friendships due to impulsive behavior.  
- Academic Functioning: The patient's grades are affected by inattention and incomplete assignments.  
- Occupational Functioning: Not applicable.  
- Home Functioning: The patient often argues with family members due to impulsivity.