ADHD Treatment Quarterly Update Scan

OMB No: ???: Exp Date: ???

_____________________

ADHD Treatment Quarterly Update

1 . Has your child been diagnosed with any of the following? (Select all that apply)

• social phobia

• generalized anxiety

• tics

• obsessive compulsive disorder

• separation anxiety

• mutism

• pica

• conduct disorder

• specific phobia

• obsessive compulsive disorder

• trichotillomania

• other

• panic disorder

• post traumatic stress disorder

• depression

• attention deficit hyper-activity disorder

• agoraphobia

• elimination disorder

• mania

If you selected ADHD (attention deficit hyper-activity disorder) above please complete the remaining form.

2 . When was your child diagnosed with ADHD?

• NA Month Year

• D on’t Know

2a. Who diagnosed your child with ADHD? Name Profession:

• Not applicable

• Missing/ Don’t Know

2 b. Where (city) is this professional located?

3. Are you affiliated with a support group for your child’s condition?

• No

• Y es

If yes, please list support groups:

4. Has your child received medication as part of his/her treatment in the past 12 months?

• N o

• Yes

4a. If yes, was any of the cost covered by insurance?

• No

• Yes

4 b. (enter average monetary cost) $

4c. Who administers the medication to your child? Select all that apply

O Parent

O School Nurse/Personnel/Other

O Child

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA ???).

4d. How many medications has your child taken in the past 12 months?

P lease list below:

Medication 1: Start Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 2: S tart Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 3: Start Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 4: S tart Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

5. Has your child taken dietary supplements (vitamins and/or herbs) as part of his/her treatment in the past 12 months?

O No

O Yes

5 a. If yes, How many?

5 b. What was the cost to you? (enter average monetary cost) $

5c. Please list (zinc, chamomile, kava hops, lemon balm, valerian root, passionflower, melatonin, ginko biloba, pycnogenol, nystatin, ketonazole, piracetam, dimethylaminoethanol, linoleic, linolenic acids, megavitamins):

V itamin 1: How many mg per day? V itamin 2: How many mg per day?

V itamin 3: How many mg per day? V itamin 4: How many mg per day?

6. In the past year, have you received parent training as related to the child’s treatment? (parent training includes: counseling, behavior modification training, or other parent training)

• No

• Y es

6a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

6b. Was it for:

• ADHD

• Other ___________________

6 c. Number of times hours

6d. Was any of the cost covered by insurance?

• No

• Yes

6 e. What was the cost to you? (enter average monetary cost) $

7 . In the past 12 months, has your child received social skills training as related to his/her treatment?

• No

• Yes

7a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

7b. Was it for:

• A DHD

• Other ___________________

7 c. Number of times hours

7d. Was any of the cost covered by insurance?

• No

• Yes

7 e. What was the cost to you? (enter average monetary cost) $

8 . In the past 12 months, has your child received school or classroom programs as related to his/her treatment? (school or classroom programs include: classroom modifications, preferential seating, testing accommodations, and behavior management plans applied in the classroom or school)

• No

• Yes

8a. If yes, Provided by:

• Teacher

• School Counselor/Psychologist

• Other ___________________

8b. Was it for:

• ADHD

• Other ___________________

8 c. Number of times hours

8d. Was any of the cost covered by insurance?

• No

• Yes

8 e. What was the cost to you? (enter average monetary cost) $

9. In the past 12 months, has your child received counseling as related to his/her treatment?

• N o

• Yes

9a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

9b. Was it for:

• ADHD

• Other ___________________

9 c. Number of times hours

9 d. Type:

• Individual

• Group

9e. Was any of the cost covered by insurance?

• No

• Yes

9 f. What was the cost to you? (enter average monetary cost) $

10. In the past year, has your child made dietary changes as related to the child’s treatment?

• N o

• Yes

10a.If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

1 0b.Time on diet (months)

10c.Was it for:

• ADHD

• Other ___________________

1 0d.Type of diet

1 1. In the past year, has your child received “alternative” services (i.e. EEG biofeedback or sensory integration) as related to his/her treatment?

• No

• Yes

11a. If yes, list below:

11b. Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

1 1c. Number of times hours

11d. Was any of the cost covered by insurance?

• No

• Yes

1 1e. What was the cost to you? (enter average monetary cost) $

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