ADHD Diagnostic Evaluation Note

Date: [Date]

Patient Name: [Patient full name]

Date of Birth: [DOB]

Clinician: [Clinician name, degrees/credentials]

Setting: [outpatient clinic / telehealth]

Visit Type: Initial ADHD Diagnostic Evaluation

Participants: [Patient; caregivers/informants present; interpreter if used] (For adolescents, note whether a portion was conducted with the patient alone.)

Referral source: [Who referred and reason for referral]

Information Sources and Limitations

• [Informants interviewed and relationship to patient]
• [Records reviewed with types and dates] (Prior evaluations, IEP/504 plans, report cards, psychoeducational testing, prior treatment records.)
• [Rating scales obtained: instrument, respondent, date] (Include only if obtained.)
• [Limitations/pending collateral] (Note outstanding data affecting diagnostic confidence.)

Chief Concern

[Presenting concern in patient/family words, 1–2 sentences]

History of Present Illness

[Narrative summary: approximate age/grade when concerns began; progression over time; current symptom pattern across inattention and hyperactivity/impulsivity domains with real-world examples; settings affected; duration and persistence; prior interventions and response; strengths/protective factors.] (Do not list DSM-5 symptom checklist here; reserve structured criteria for the DSM-5 section.)

Functional Impairment

(Document concrete impairment in at least two settings. If impairment in two or more settings cannot be established, explicitly state this and outline the plan to obtain additional collateral. Do not infer cross-setting impairment.)

Academic/Work: [Performance relative to ability; missing/incomplete work; organization difficulties; behavior concerns; attendance; existing supports and effectiveness]

Home: [Routine difficulties; need for repeated prompts; conflict with household members; safety concerns if present]

Social: [Peer/colleague relationships; conflict/rejection; emotional dysregulation impacting relationships]

Other domains: [Extracurricular participation; driving concerns; risky behaviors; financial/organizational impacts] (Include only if relevant.)

DSM-5 ADHD Criteria

Inattention Symptoms

• [Endorsed symptom: brief anchor example; evidence source] (List each endorsed symptom with example and source.)

Total inattention symptoms endorsed: [Count] — [Threshold met / not met for age]

Hyperactivity/Impulsivity Symptoms

• [Endorsed symptom: brief anchor example; evidence source] (List each endorsed symptom with example and source.)

Total hyperactivity/impulsivity symptoms endorsed: [Count] — [Threshold met / not met for age]

Required Criteria

• Onset before age 12: [Yes / No / Unclear] — [Evidence and source]
• Duration: [Chronic / Transient / Unclear] — [Time course description]
• Cross-situational presence: [Settings with evidence sources] (At least two settings required.)
• Clinically significant impairment: [Yes / No / Unclear] — [Link to Functional Impairment section]
• Alternative explanations considered: [Summary of conditions ruled out with rationale]

(If any required elements are unclear or not yet established, explicitly mark as such and include plan to obtain needed information. Do not infer.)

Presentation and Severity

ADHD presentation: [Predominantly inattentive / Predominantly hyperactive-impulsive / Combined / Criteria not met] — [Brief rationale]

Severity: [Mild / Moderate / Severe] (If criteria met, based on symptom count, cross-setting impairment, and support needs.)

Diagnostic status: [Confirmed / Provisional / Deferred] — [Rationale and next steps if not confirmed]

Rating Scales

(Include this section only if rating scales were used. State explicitly that rating scales support but do not replace clinical assessment.)

• [Instrument name] — [Respondent/relationship], [Date]: [Scores] — [Clinical interpretation per norms]

[Cross-informant agreement/discrepancy and clinical interpretation]

Comorbidity and Differential Screening

Psychiatric:

• Anxiety: [present / absent / unclear] — [Brief details]
• Depressive symptoms/irritability: [present / absent / unclear] — [Brief details]
• Oppositional/conduct behaviors: [present / absent / unclear] — [Brief details]
• Trauma history/symptoms: [present / absent / unclear] — [Brief details]
• Substance use: [present / absent / unclear / not assessed] — [Brief details] (Assess in adolescents/adults.)
• Suicidality/self-harm: [present / absent / unclear] — [Risk assessment summary] (Include if indicated.)

Neurodevelopmental:

• Learning disorder concerns: [present / absent / unclear] — [Testing indicated?]
• Language concerns: [present / absent / unclear] — [Brief details]
• Autism-spectrum traits: [present / absent / unclear] — [Brief details]
• Tic symptoms: [present / absent / unclear] — [Brief details]

Sleep and Medical:

• Sleep duration/quality: [adequate / inadequate / unclear] — [Snoring/apnea symptoms]
• Headaches/neurologic symptoms: [present / absent / unclear] — [Brief details]
• Thyroid/metabolic concerns: [present / absent / unclear] — [Brief details]
• Medication/caffeine/substance contributions: [present / absent / unclear] — [Brief details]

Relevant History

• Developmental: [Pregnancy/birth; milestones; early temperament] (Required for pediatric evaluations.)
• Past psychiatric: [Prior diagnoses/evaluations; therapy; hospitalizations; prior medication trials with response/side effects]
• Medical: [Relevant conditions; cardiac history/symptoms; growth concerns]
• Medications: [Current medications and supplements; allergies]
• Family history: [ADHD; learning disorders; tics; mood/anxiety disorders; substance use in first-degree relatives]
• Social: [Household composition; custody; major stressors; school/grade/program or workplace]

Examination

Vitals: [Height; Weight; BMI percentile (pediatrics); Blood pressure; Pulse] (Required if medication is being considered.)

Mental Status Exam: [Appearance; behavior; motor activity; speech; mood/affect; thought process; attention and impulsivity observed; insight/judgment] (Brief clinic observations should not be overweighted relative to longitudinal multi-informant reports.)

Differential Diagnosis

• Most likely diagnosis: [Diagnosis] — [Supporting evidence]
• ADHD vs anxiety/depression: [For/against]
• ADHD vs learning/language disorder: [For/against]
• ADHD vs sleep disorder: [For/against]
• ADHD vs trauma-related symptoms: [For/against]
• ADHD vs mood instability: [For/against]
• ADHD vs autism-related executive dysfunction: [For/against]
• Medical mimics/substance effects: [For/against]

Assessment

Diagnostic conclusion: [ADHD criteria met / not met / provisional / deferred pending additional information] — [All diagnoses including comorbidities with certainty level]

Formulation: [Integrative paragraph: symptom pattern, functional impairment across settings, relevant history, comorbidities, protective factors, key supporting evidence, and any contradictory findings]

Plan

ADHD or Suspected ADHD

• Psychoeducation: [ADHD conceptualization reviewed; treatment options discussed; patient/family preferences documented]
• Behavioral interventions: [Parent training/behavioral strategies; routine modifications; organizational supports]
• School/Work supports: [Recommended accommodations; 504/IEP or workplace adjustment indicated; letter provided; ROI status]
• Medication: [Baseline cardiac screen; vitals; diversion risk assessment (adolescents/adults); medication discussed with risks/benefits; selected medication and dosing; target symptoms; monitoring plan; safe storage counseling; follow-up interval] (If deferring medication, document rationale and criteria to reconsider.)
• Referrals: [Psychoeducational testing; speech/language evaluation; therapy; sleep evaluation; other specialties as indicated]
• Follow-up: [Next appointment; collateral to obtain; communication plan with school/PCP/therapist]

Additional Problems

• [Problem]: [Problem-specific plan] (Add entries for each additional identified problem such as anxiety, sleep concerns, or safety concerns.)