Consultation - Mentor Pharmacy

1 Before You Begin

Thank you for completing this form. This questionnaire collects the information needed before arranging an ADHD assessment and considering whether prescribing may be appropriate within this service. This form does not provide a diagnosis and does not guarantee treatment or prescribing. Some answers may mean that further review is required before the next stage.

I understand that this form is for information gathering and screening only, and that prescribing decisions will only be made after clinical assessment. I understand that all answers are truthful and answered to the best of my knowledge.

3 Referral Reason and Goals

What has led you to seek an ADHD assessment at this time?

What symptoms are causing you the most difficulty?

In which areas of your life are these difficulties affecting you? (select all that apply)

What are you hoping to gain from this assessment?

4 ADHD Symptoms and Current Impairment

Please answer the following questions about how often these symptoms affect you. There are no right or wrong answers.

ADHD Symptom Self-Report Scale

Developer note: This section is a placeholder. The validated self-report instrument (ASRS-v1.1 or equivalent) will be inserted here prior to build, with clinical sign-off required before this section goes live.

11 Sleep, Appetite, and Weight

Do you have significant sleep problems?

Yes

Do you have problems with appetite, weight loss, restrictive eating, or concerns about your weight?

Yes

12 Baseline Observations

Some ADHD medications can affect blood pressure and heart rate. These measurements are required to assess prescribing safety. If you do not know your readings, you may be able to check at a local pharmacy.

Height (cm)

Please enter your height in centimetres (e.g. 175).

Weight (kg)

Please enter your weight in kilograms (e.g. 80).

Do you know your recent blood pressure reading?

Clinical note: systolic blood pressure at or above 160 mmHg or diastolic at or above 100 mmHg will be flagged for clinical review. Slightly elevated readings below this threshold are also reviewed.

Yes

Do you know your recent resting pulse rate?

Yes

13 Reproductive Health

This section applies to patients who were registered female at birth. It is shown automatically based on your earlier answer. If this section is relevant to you but has not appeared, please let your clinician know during assessment.

14 Family History

Is there a family history of ADHD?

Informational only and does not affect your eligibility for assessment.

Yes

Unsure

Is there a family history of autism, bipolar disorder, psychosis, or other significant mental illness?

Yes

Unsure

Is there a family history of sudden cardiac death, inherited heart disease, long QT syndrome, or cardiomyopathy?

Yes

Unsure

16 Consent and Declaration

Do you consent to us contacting your GP if clinically necessary?

Declining GP contact may limit your prescribing pathway but will not automatically prevent your assessment.

Yes

Do you consent to us requesting collateral history from someone who knows you well, if clinically needed?

Yes

I understand that assessment does not guarantee diagnosis.

I understand that diagnosis does not guarantee prescribing.

I confirm that the information I have provided is accurate and truthful to the best of my knowledge.

I agree that any medication prescribed must only be taken exactly as prescribed and must not be shared, sold, or diverted to others.

I understand that it is an offence to supply, sell, or divert prescribed controlled medication to another person.

I agree to inform the prescriber immediately of any changes in my health, medications, side effects, or circumstances that may affect treatment.

1 Before You Begin
2 Patient Details
3 Referral Reason and Goals
4 ADHD Symptoms and Current Impairment
5 Childhood History
6 Education and Occupational History
7 Physical Health History
8 Current Medications and Allergies
9 Mental Health History
10 Substance Use and Misuse Risk
11 Sleep, Appetite, and Weight
12 Baseline Observations
13 Reproductive Health
14 Family History
15 Safeguarding and Practical Risk
16 Consent and Declaration

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for ADHD

1 Before You Begin

I understand that this form is for information gathering and screening only, and that prescribing decisions will only be made after clinical assessment. I understand that all answers are truthful and answered to the best of my knowledge.

2 Patient Details

Title

Please enter your title

Full name

Preferred name

Date of birth

Sex registered at birth

Gender identity

NHS number

Full postal address

Postcode

Country of residence

Primary phone number

Secondary phone number

Email address

Preferred contact method

Are you registered with a GP?

GP practice name

GP practice address

GP practice postcode

GP practice phone number

Next of kin / emergency contact name

I confirm I consent to this person being contacted in an emergency or if there are concerns about my safety.

Relationship to you

Emergency contact phone number

Emergency contact email

Occupation

Employer

Do you drive?

Do you hold a UK driving licence?

Are you currently working in a safety-critical role? (e.g. healthcare, transport, machinery, working at heights)

Please provide details.

3 Referral Reason and Goals

What has led you to seek an ADHD assessment at this time?

What symptoms are causing you the most difficulty?

In which areas of your life are these difficulties affecting you? (select all that apply)

Please tell us more.

What are you hoping to gain from this assessment?

4 ADHD Symptoms and Current Impairment

ADHD Symptom Self-Report Scale

5 Childhood History

Do you believe your difficulties were present before the age of 12?

Did teachers or family members ever comment on inattention, overactivity, impulsivity, poor organisation, or behavioural difficulties?

Did you have difficulties at school with concentration, behaviour, homework, deadlines, or detentions?

Were you ever assessed for ADHD, autism, dyslexia, dyspraxia, or another developmental condition?

If yes, please provide details of any previous assessments or diagnoses.

Do you have access to school reports, or someone who knew you well in childhood who could provide collateral history?

Do you believe your current difficulties are better explained by another condition (e.g. anxiety, depression, trauma, autism)?

6 Education and Occupational History

Highest level of education completed

Did you receive additional support in education?

Please give details of any educational support or learning difficulties identified (e.g. dyslexia, EHCP, ASD, support worker).

Are you currently employed?

Current occupation

Have your symptoms affected your work performance, timekeeping, organisation, or relationships at work?

Please describe any impact your symptoms have had on your education or employment.

7 Physical Health History

Have you ever been diagnosed with a heart condition?

Please provide details of the heart condition.

Have you ever been told you have a heart rhythm problem or arrhythmia?

Have you ever fainted or blacked out unexpectedly without a clear cause?

Do you get chest pain on exertion?

Do you experience palpitations (awareness of your heartbeat, racing, or irregular rhythm)?

Have you ever been told you have high blood pressure?

Is your blood pressure currently well controlled?

Have you ever been told your resting heart rate is unusually high?