MEDICAL HISTORY FORM

First Name

Surname

Date of Birth

Date

Age

Sex (as assigned at birth)

Pronouns

Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail Address

GP Name:

GP email (if known)

example@example.com

GP Surgery Name and Address:

In order to prescribe your medication safely, Headspace will need to view your medical records which are held by your GP surgery. Headspace will specifically request to view only pertinent health information relating to your medication, allergies and medical conditions. This information will be received electronically and stored securely whilst you are a patient at Headspace, in accordance with GDPR and Data Protection Laws, then deleted after discharge. If you consent to Headspace accessing your medical information, please sign and type your name below.

Name

First NameLast Name

Please upload a copy of photo ID (acceptable forms include: passport, driving licence, blue badge, PASS card).

As ADHD medications are schedule 2 controlled drugs in the UK, photo ID is required by Headspace before prescriptions can be written. The supplied ID will also need to be viewed by partner pharmacy (Health Plus Pharmacy, Torfaen) if you opt to use their dispensing and delivery services.

Height (cm)

Weight (kg)

Blood Pressure and Pulse (if known)

Please be advised that you will need to purchase a blood pressure machine to take readings at home (before starting medication and at regular intervals during titration), unless attending the clinic for your appointments.

Do you have any allergies?

Are you currently pregnant or breastfeeding? Or trying to conceive?

Do you have any medical conditions?

Do you take any medication? (including herbal supplements)

Are you currently receiving any medical treatment?

Have you ever experienced any of the following?

Rows	Yes	No
Overactive thyroid
Phaeochromocytoma brain tumour
Vasculitis
Epilepsy
Glaucoma
Family history of Glaucoma
Stroke
Brain aneurysm
Brain bleed
Carotid artery disease
Anaphylactic Shock
Migraine
Cerebral aneurysm
Vasculitis
Kidney disease
Liver disease
Anaemia
Blood disorders
Dysphagia/Difficulty Swallowing
Gastrointestinal problems
Rheumatoid arthritis
Lupus
Erectile dysfunction
Marfan Syndrome

If you have ticked yes to any of the above, please provide details:

Have you ever experienced any of the following?

Rows	Yes	No
Anorexia
Psychosis
Severe Depression
Suicidal Ideation
Bipolar disorder
Anxiety
Tourette’s Syndrome
Family history of Tourette’s Syndrome
Addiction
Family history of mental illness or suicide
Currently/recently taken antidepressants
Personality disorder
Extremes of mood
Tics/Tic disorder

If you have ticked yes to any of the above, please provide details:

Have you ever had any of the following?

Rows	Yes	No
Heart Surgery
Heart Disease
Sudden death of relative under 40
Shortness of breath or chest pain when exercising compared to peers
Fainting in response to fright or noise or exercise
Palpitations that are rapid, regular and start/stop suddenly
Chest pain
High Blood Pressure
Low Blood Pressure
Heart abnormalities
High cholesterol
Arrhythmias
Cardiomyopathy
Heart failure
Coronary artery disease
Arterial occlusive disease / Arteriosclerosis
Angina
Heart Attack
Any other heart condition
Heart murmur
Heart disease, angina or heart attack in 1st degree relative under 60?
Atrial fibrillation

If you have ticked yes to any of the above, please provide details:

How many units of alcohol do you tend to drink per week?

Would you describe yourself as alcohol or drug dependent?

Do you currently use non-prescribed drugs?

Have you ever used prescribed drugs recreationally?

Have you ever had a reaction to amphetamine based drugs?

Do you smoke?

Please add any other important information here:

ADHD Symptoms Rating Scale (Adapted from Adult Self-Report Scale-V1.1, Kessler et al 2005)

Rows	Never	Rarely	Sometimes	Often	Very Often
How often do you have difficulty wrapping up the final details of a project, once the challenging parts have been done?
Have often do you forget appointments?
How often do you put off tasks that require a lot of thought?
How often do you fidget when you have to sit down for long periods?
How often do you struggle to get things in order for a task that requires organisation?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you even when they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or situations where you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing?
How often do you find yourself talking too much when in social situations?
How often do you find yourself finishing sentences of people you are talking to, before they can finish themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?

Please add any other ADHD traits or symptoms you’d like to monitor here, and how often they affect you:

Please upload your ADHD diagnosis report here:

All Information provided on this form is confidential and secure. This information is held solely for the purpose of providing medical care and will only be shared with your permission to aid your health and treatment.

Please tick to confirm

Name

First name Surname

Signature

CONSULTATION FORM

Personal Details

General Health

Physical Health

Mental Health

Heart Health

Alcohol/Drugs

PRIVACY CONSENT