Comprehensive Adult ADHD Evaluation Template

Identifying Information

Patient's Name: Marcus Vance Date of Birth: 14/08/1992 Gender: Male Date of Assessment: 24/10/2023

Reason for Assessment: Self-referred due to chronic difficulties with focus, task completion, and time management, resulting in a recent Performance Improvement Plan (PIP) at work.

Mental State Examination

appearance and behaviour - Casually dressed, well-groomed. Cooperative. Frequent leg bouncing and pen clicking observed throughout the session. speech patterns - Rapid rate, normal volume and tone; interruptive at times. mood and affect - Mood described as "stressed"; affect anxious and reactive. thought processes - Tangential when providing history; requires frequent redirection. No delusions or hallucinations. attention and concentration during the interview - Easily distracted by outside corridor noise; lost train of thought three times during interview. level of insight into their difficulties - Good; recognises impact of symptoms on occupational functioning and relationships.

Patient History

developmental history - Uncomplicated term birth. Normal developmental milestones. Described by parents as "hyper and daydreamy" in primary school. family history of ADHD or other psychiatric conditions - Brother diagnosed with ADHD in childhood; mother has history of GAD. past and current medical conditions - Mild intermittent asthma. No history of head trauma, seizures, or sleep disorders. Current meds: salbutamol (albuterol, ProAir HFA®) 90 mcg INH PRN. Baseline vitals: BP 118/76 mmHg, HR 72 bpm. Recent TFTs and CBC WNL. educational history - High intellectual capacity noted, but inconsistent grades. Frequently reprimanded for talking in class and forgetting homework. Completed BSc in Computer Science, requiring an extra year due to failed coursework deadlines. employment history - Software developer. Changed jobs 4 times in 5 years due to boredom or poor performance reviews regarding missed deadlines and documentation errors. Currently on a PIP. current and past substance use - Consumes 4–5 cups of coffee daily to "help focus." Social EtOH (2–3 drinks/week). Denies tobacco or illicit substances. previous psychiatric diagnoses - Treated for adjustment disorder with anxious mood in 2019 (6 months of CBT, partial benefit; no pharmacotherapy).

Inattention

any issues with attention to detail - Frequently submits code with syntax errors due to skipping final review steps. any difficulties sustaining attention - Unable to focus during 30-minute team stand-up meetings; struggles to read technical manuals. active listening - Partner frequently complains that he "zones out" during direct conversations at home. issues following instructions - Starts multiple projects simultaneously at work and home, leaving the majority ~80% complete. difficulties organising tasks - Desk and digital workspaces are cluttered; chronic underestimation of time required to complete tasks. any avoidance or reluctance to undertake tasks - Procrastinates heavily on administrative tasks, expense reports, and tax filings. any tendency to lose items - Misplaces keys, wallet, or security badge at least 3–4 times per week. distractions: High frequency; easily derailed by email notifications, background conversations, and unrelated internal thoughts. forgetfulness - Frequently misses scheduled appointments and forgets to pay utility bills despite having funds, leading to late fees.

Hyperactivity

fidgeting or squirming - Constant foot tapping, knee bouncing, and manipulation of desk objects. leaving seat - Finds excuses to leave desk frequently during the workday (e.g., excessive trips to the breakroom). restlessness - Reports persistent internal sense of restlessness and inability to relax in the evenings. difficulty with quiet activities - Unable to watch a full movie without checking phone or getting up to do chores. feeling “on the go” - Describes feeling "wired" and uncomfortable when having unstructured downtime. talking excessively - Tends to dominate conversations and over-explain concepts.

Impulsivity

blurting answers - Frequently finishes colleagues' sentences in meetings. waiting turn - Experiences significant frustration and impatience when waiting in queues or traffic. interrupting or intruding - Interrupts coworkers and partner regularly to voice thoughts before forgetting them.

Symptom Severity & Diagnostic Prompts

symptom tallies - 9/9 inattentive symptoms; 6/9 hyperactive-impulsive symptoms. functional impairment - Moderate-to-severe occupational impairment (at risk of job loss) and mild-to-moderate social/home impairment (interpersonal friction with partner over household responsibilities). age of onset - Multiple inattentive and hyperactive symptoms present prior to age 12, corroborated by primary school report cards reviewed today. differential diagnosis - Symptoms are not better explained by GAD, mood disorders, substance use, or general medical conditions (thyroid panel normal). Anxiety appears secondary to executive dysfunction stressors. final diagnostic impressions - Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2), moderate severity. Plan: Initiate lisdexamfetamine (Vyvanse®) 30 mg PO QAM, refer for ADHD-focused CBT, and review in 4 weeks with repeat BP/HR check.