Pediatric ADHD follow-up template

Pediatric ADHD Follow-Up Note

Visit Context
- Interval since last ADHD visit; who is present (patient, parents/caregivers, school reports).
- Current treatment goals (attention, impulsivity, homework completion, behavior, peer function).

Interval History — Symptoms & Function
- Home and school function: attention, hyperactivity/impulsivity, organization, grades, behavior referrals, peer relationships.
- Mood, anxiety, tics, sleep, and appetite changes.
- Collateral from teachers or caregivers if discussed.

Rating Scales
- Scales reviewed (e.g., Vanderbilt) and scores/trends if provided—do not invent scores.
- Note incomplete forms or need for updated teacher input.

Current ADHD Medications
- Medication name, dose, timing (school days vs weekends), adherence, and missed doses.
- Perceived benefit duration (e.g., wear-off timing) and any diversion/safety concerns discussed.

Side Effects & Growth
- Appetite, weight/height trajectory, sleep onset/maintenance, headaches, irritability, tics, BP/HR if measured.
- Other adverse effects and tolerability.

Comorbid Considerations
- Learning differences, anxiety, depression, ODD/conduct concerns, sleep disorders, substance exposure (adolescents) as relevant.

Exam
- Vital signs including BP/HR and growth parameters as obtained; focused exam as performed.

Assessment
- ADHD presentation type and current control (well controlled / partial / inadequate).
- Side-effect burden and adherence assessment.
- Comorbidities affecting management.

Plan
- Medication adjustments or continuation with rationale; timing changes; holiday/weekend strategies if used.
- Behavioral strategies, school supports (504/IEP), counseling referrals, sleep/nutrition counseling.
- Monitoring plan (growth, BP/HR, rating scales) and follow-up interval.
- Controlled-substance counseling and secure storage as discussed.