Fillable Attention Deficit (Hyperactivity) Disorder Documentation Form (Raritan Valley Community College)

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Attention Deficit (Hyperactivity) Disorder Documentation Form (Raritan Valley Community College)

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DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Attention Deficit (Hyperactivity) Disorder Documentation Form
This form is to be used in cases where an updated/current, diagnostic evaluation report is not available. It is to
be completed by a treating neuropsychologist, neurologist, or psychiatrist.
Please complete this form with as much detail as possible, as a partially completed form or limited responses
may hinder the eligibility process. It is most important that you thoroughly explain any symptoms and indicate
their impact on functioning. If you wish to provide additional information, please attach it to these forms.
Thank you for your assistance.
To be completed by the treating, licensed healthcare professional only
Student’s name: ___________________________________________________________________________
Today's date: ________________________
Age of onset/diagnosis ________________
Date of initial contact with student: _________________ Date student was last seen: __________________
Frequency of appointments ____________________________________________________
DSM-V Diagnosis:
314.01 Combined Presentation
314.00 Predominantly Inattentive Presentation
314.01 Predominantly Hyperactive/impulsive Presentation
314.01 Unspecified Attention-Deficit/Hyperactivity Disorder
Specify current severity: Mild Moderate Severe
Explain the severity checked above: __________________________________________________________
Additional Diagnosis (es)/Comorbidities:
_______________________________________________________________________________________
Please check the specific symptoms student is experiencing (based on DSM-V criteria):
Hyperactivity and impulsivity:
Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the
classroom, in the office or other workplace, or in other situations that require remaining in place).
Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still
for extended time, may be experienced by others as being restless or difficult to keep up with).
✔
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Often blurts out an answer before a question has been completed (e.g., completes people’s sentences;
cannot wait for turn in conversation).
Often has difficulty waiting his or her turn (e.g., while waiting in line).
Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using
other people’s things without asking or receiving permission; intrude into or take over what others are
doing).
Inattention:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during
other activities (e.g., overlooks or misses details, work is inaccurate).
Often has difficulty sustaining attention in tasks (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence
of any obvious distraction).
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty
keeping materials and belongings in order; messy, disorganized work; has poor time management; fails
to meet deadlines).
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g.,
schoolwork or homework; preparing reports, completing forms, reviewing lengthy papers).
Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, cell phones).
Is often easily distracted by extraneous stimuli (may include unrelated thoughts).
Is often forgetful in daily activities (e.g., doing chores, running errands, returning calls, paying bills,
keeping appointments).
In addition to DSM-V criteria, how did you arrive at your diagnosis? Please check all relevant items below,
adding brief notes that you think might be helpful to us as we determine which accommodations and services
are appropriate for the student.
Interviews with other persons
Behavioral observations
Developmental History
Educational history
Medical history
Testing (attach a copy of the report). Dates and type of testing:
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Student History:
1. ADHD History: According to the DSM-V, several inattentive or hyperactive- impulsive symptoms must be
present prior to age 12 years. Provide information supporting the diagnosis obtained from student/parent(s)/
teacher(s). List the symptoms that were present during early school years (e.g. day dreamer, spoke out of turn,
unable to sit still, disruptive, difficulty understanding directions etc.)
_________________________________________________________________________________________
_________________________________________________________________________________________
2. Psychological History: Describe any relevant psychological history. Include any psychological evaluations or
testing implemented, if applicable.
_________________________________________________________________________________________
_________________________________________________________________________________________
Level of Impact:
Identify the level of impact the student’s ADHD has on major life activities and learning by choosing best
option from drop down below.
1= Unknown 2 = No Impact 3 = Mild Impact 4 = Moderate Impact 5 = Substantial Impact
Organizing/Planning/Prioritizing
Managing external distractions
Managing internal distractions
Timely completion of assignments
Attending classes on time
Managing deadlines
Collaborating on group projects
Concentrating
Managing stress
Interacting with others
Memory
Sleeping
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Self-care
Social interaction
List the student’s current medication(s), including dosage, frequency, and adverse side effects (if applicable):
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there significant limitations to the student’s functioning directly related to the prescribed medications?
___ Yes ____ No If yes, explain: ____________________________________________________________
Certifying Professional
____________________________________ ______________________________
Name and Title Area of Specialty
____________________________________ ______________________________
License Number State of Licensure
____________________________________ ______________________________
Address Phone Number
____________________________________ ______________________________
City, State, Zip Fax Number
____________________________________ ______________________________
Signature of Certifying Professional Date
Please Return to:
Disability Services - Raritan Valley Community College
College Center C-124
Fax (908) 526-3494
disabilityservices2@raritanval.edu
Unknown
Unknown
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Attention Deficit (Hyperactivity) Disorder Documentation Form (Raritan Valley Community College)

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Completed 26 July 2020

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