Use this form to record information about your child's treatment plan for attention deficit hyperactivity disorder (ADHD). Review the plan with your doctor or other health professional often. Together you can keep the plan up to date.
My child's main symptom of ADHD is (inattention, impulsiveness, or hyperactivity) ______________________.
An example of this symptom is:
My child expresses the other symptoms of ADHD in the following ways.
My child takes the following medicine for ADHD at the listed times.
My child has the following learning disabilities or other medical conditions often associated with ADHD. (If not applicable, cross out this statement.)
We are helping my child control the following behaviour.
We are using the following consequences or methods to help my child control behaviour.
My child is participating in a social skills training program to learn:
Other things about my child's health:
Current as ofSeptember 11, 2018
Author: Healthwise Staff Medical Review: Adam Husney, MD - Family Medicine Kathleen Romito, MD - Family Medicine Louis Pellegrino, MD - Developmental Pediatrics
Medical Review:Adam Husney, MD - Family Medicine & Kathleen Romito, MD - Family Medicine & Louis Pellegrino, MD - Developmental Pediatrics