Help us prepare for your appointment by completing this form in advance.
We need this form before your ADHD assessment. It includes the ASRS-5 screening tool and a full clinical history that your doctor will use as part of the diagnostic process - it's not something we can do without.
It takes about 10 minutes, and every answer helps us give you a thorough, well-prepared assessment. Take your time, be honest, and don't overthink it.
ASRS-5 Q1. Score: Never=0, Rarely=0, Sometimes=1, Often=1, Very Often=1
ASRS-5 Q2
ASRS-5 Q3
ASRS-5 Q4
ASRS-5 Q5. Total score 14+ = probable ADHD (90% sensitivity, 88% specificity)
Examples: overlooks details in reports, makes errors in forms, work is inaccurate, misses steps in procedures
Examples: careless errors in homework, missed questions on tests, didn't check work
Examples: mind wanders during meetings, can't finish reading a chapter, zones out in conversations
Examples: couldn't concentrate during lessons, got bored quickly with activities, needed things to be interesting
Examples: partner complains you don't listen, miss instructions in meetings, people repeat themselves
Examples: 'in a world of your own', teacher had to repeat instructions, appeared to daydream
Examples: starts tasks but gets sidetracked, doesn't finish paperwork, leaves projects half-done
Examples: difficulty managing sequential tasks, keeping materials in order, messy/disorganised work, poor time management, missing deadlines
Examples: puts off tax returns, avoids long documents, dreads admin tasks
Includes both external distractions (noise, movement) and internal (unrelated thoughts, daydreaming)
Examples: tapping feet, clicking pens, playing with hair, can't sit still in meetings
Examples: gets up during meetings, can't sit through a film, paces while on phone
In adults this manifests as subjective restlessness rather than running/climbing
Examples: can't read quietly, always needs TV/music on, talks during films, can't relax without stimulation
Examples: others say you talk too much, dominate conversations, can't stop yourself talking
Examples: impatient in queues, cuts into conversations, difficulty waiting for things
DSM-5 requires several symptoms present before age 12. Symptoms starting after age 12 may suggest another cause.
DSM-5 requires symptoms in 2+ settings (e.g. work AND home)
These questions help us understand childhood experiences that may affect your mental health. Childhood adversity can mimic or worsen ADHD symptoms. Answer honestly - there are no judgments.
IMPORTANT: Screens for bipolar disorder - stimulant medication may be contraindicated
Red flag for bipolar disorder - stimulants may be contraindicated
Tics can worsen with stimulant medication
Substance use history affects medication choice - lisdexamfetamine preferred if history present
Sleep problems are very common in ADHD and can worsen symptoms. Stimulant medication timing may need adjustment.
Stimulant medication can reduce appetite. Important to monitor if eating disorder history.
CRITICAL: Family history of sudden cardiac death requires ECG before stimulant medication
SAFETY SCREEN: Psychotic symptoms are an absolute contraindication for stimulant medication
SAFETY QUESTION: Your response helps us ensure you receive appropriate support
Most ADHD medications have limited safety data in pregnancy
Some ADHD medications lower seizure threshold
Atomoxetine is metabolised by the liver - dose adjustment needed if impaired
Stimulant medications can increase intraocular pressure
Contraindications for stimulant medication
NICE guidelines recommend collateral information from someone who has known you well, ideally since childhood. This strengthens your assessment.
Previous ADHD assessments, school reports, educational psychologist reports, GP referral letters, or any other relevant documents. Childhood evidence is particularly valuable for diagnosis.
Anything you would like your doctor to know before your appointment.
Your information is sent securely to your doctor at LoveMyLife. We will not share your details with third parties. By submitting this form, you consent to LoveMyLife contacting you regarding your appointment.