ADHD Rating Scale
Please provide the following information about yourself and the client before proceeding to the ADHD Rating Scale.
CLINICIAN INFORMATION
Clinician Name :
  
Discipline :
  
Location :
  
YOUR INFORMATION
First Name :
 
Last Name :
 
Birthdate :
 
MM
DD
YYYY
Gender :
 
Female
Grade :
  
Pre
Kinder
1
2
3
4
5
6
7
8
9
10
11
12
CURRENT MEDICATIONS
Are you taking any medications for ADHD?
Yes   No
NAME and DOSE of Current ADHD Medication(s)?:
 
1.
Total Daily Dose
Add Medication
  
2.
Total Daily Dose
Delete
Add Medication
  
3.
Total Daily Dose
Delete
Add Medication
  
4.
Total Daily Dose
Delete
Add Medication
  
5.
Total Daily Dose
Delete
Are you taking any OTHER medications?
Yes   No
NAME and DOSE of Other Medication(s)?:
 
Any other comments regarding medications?