DVMH

Da Vinci Mental Health

Adult ADHD Intake & Assessment Module (Self-Report)

Progress

Please complete all sections below as thoroughly as possible. Fields marked * are required.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Used to file this form with the correct patient record. (Not part of the original paper form.)

Date*

Section 1 - ADHD Screen (ASRS-Style Core)

Over the past 6 months, how often have you experienced the following?*

(0 = Never | 1 = Rarely | 2 = Sometimes | 3 = Often | 4 = Very Often)

Inattention

Question	0	1	2	3	4

Hyperactivity / Impulsivity

Question	0	1	2	3	4

Total Score (out of 60)

Severity

Scoring: 0-15 Minimal | 16-30 Mild | 31-45 Moderate | 46+ Severe. Clinical signal: multiple items scored "Often" or "Very Often" suggests strong ADHD likelihood.

Section 2 - Functional Impairment (Critical)

Work / Productivity

Cognitive Impact

Emotional & Behavioral

Section 3 - Developmental History (Key for Diagnosis)

Childhood symptoms (before age 12):

Section 4 - Differential Screen (Important for You)

Check if present

Section 5 - Treatment History

Medications

Stimulants (Adderall, Vyvanse, etc.) Non-stimulants (Strattera, Guanfacine) Other

Medication Response

Minimal Partial Poor tolerance

Behavioral Interventions

Interventions tried

Coaching Therapy Organizational strategies

Section 6 - Clinician Summary (MDM Ready)

For clinician completion.

ADHD Total Score: - → Severity: -

Functional Impairment (from Work/Productivity): -

ADHD Type

Automatically suggested from the Inattention vs. Hyperactivity/Impulsivity subscale averages above. Please confirm or adjust as clinically appropriate.

Predominantly inattentive Hyperactive-impulsive Combined

Severity

Calculated automatically from the Total Score above.

Functional Impairment

Calculated automatically from Missed Deadlines, Disorganization, and Procrastination in Section 2 (whichever is greatest).

Your responses are sent securely to the practice. Nothing is stored in this browser.

Thank you

Your assessment has been received. Our office will follow up if anything further is needed.