Psychiatry & Psychology
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Inattention (5 or more must be present for >6 months)
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
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2. Often has trouble holding attention on tasks or play activities.
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3. Often does not seem to listen when spoken to directly.
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4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
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5. Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
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6. Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
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7. Is often easily distracted
[checkbox name="variable_7" value="Yes|No"]
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8. Is often forgetful in daily activities.
[checkbox name="variable_8" value="Yes|No"]
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Hyperactivity (5 or more must be present for >6 months)
1. Often fidgets with or taps hands or feet, or squirms in seat.
[checkbox name="variable_9" value="Yes|No"]
[text name="variable_1" default=""]

2. Often leaves seat in situations when remaining seated is expected.
[checkbox name="variable_10" value="Yes|No"]
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3. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
[checkbox name="variable_11" value="Yes|No"]
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4. Often unable to play or take part in leisure activities quietly.
[checkbox name="variable_12" value="Yes|No"]
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5. Is often “on the go” acting as if “driven by a motor”.
[checkbox name="variable_13" value="Yes|No"]
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6. Often talks excessively.
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7. Often blurts out an answer before a question has been completed.
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8. Often has trouble waiting their turn.
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9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
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Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and academic/occupational activities.
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Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.
[checkbox name="variable_19" value="Yes|No"]

Several symptoms (inattentive or hyperactive/impulsive) present in ≥2 settings (eg, at home, school, or work; with friends or relatives; in other activities).
[checkbox name="variable_20" value="Yes|No"]

There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
[checkbox name="variable_21" value="Yes|No"]

Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).
[checkbox name="variable_22" value="Yes|No"]

Do you currently have a history of any heart conditions and/or take any medications that treat high blood pressure?
[checkbox name="variable_23" value="Yes|No"]

Does anyone in your immediate family (first degree relatives) have a heart condition including but not limited to: sudden cardiac death, irregular heartbeat, or a heart attack before the age of 55?
[checkbox name="variable_24" value="Yes|No"]

Is the patient 65 years of age or younger?
[checkbox name="variable_25" value="Yes|No"]

Is there active Substance Use Disorder?
[checkbox name="variable_26" value="Yes|No"]

Is there is Substance Use Disorder history in sustained remission?
[checkbox name="variable_27" value="Yes|No"]
Inattention (5 or more must be present for >6 months)
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.



2. Often has trouble holding attention on tasks or play activities.



3. Often does not seem to listen when spoken to directly.



4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).



5. Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).



6. Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).



7. Is often easily distracted



8. Is often forgetful in daily activities.



Hyperactivity (5 or more must be present for >6 months)
1. Often fidgets with or taps hands or feet, or squirms in seat.



2. Often leaves seat in situations when remaining seated is expected.



3. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).



4. Often unable to play or take part in leisure activities quietly.



5. Is often “on the go” acting as if “driven by a motor”.



6. Often talks excessively.



7. Often blurts out an answer before a question has been completed.



8. Often has trouble waiting their turn.



9. Often interrupts or intrudes on others (e.g., butts into conversations or games)



Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and academic/occupational activities.


Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.


Several symptoms (inattentive or hyperactive/impulsive) present in ≥2 settings (eg, at home, school, or work; with friends or relatives; in other activities).


There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.


Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).


Do you currently have a history of any heart conditions and/or take any medications that treat high blood pressure?


Does anyone in your immediate family (first degree relatives) have a heart condition including but not limited to: sudden cardiac death, irregular heartbeat, or a heart attack before the age of 55?


Is the patient 65 years of age or younger?


Is there active Substance Use Disorder?


Is there is Substance Use Disorder history in sustained remission?

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