ADHD Self Report Form - drmusasami.co.uk

Step 1 of 6 — About you

ADHD Self Report

Please tell us about your experiences in your own words. This helps the clinician understand how symptoms affect your daily life.

Patient ID

Full name

Email address

Phone number

Step 2 of 6 — Current difficulties

Current symptoms

Describe the main difficulties you experience now.

What are the main attention or concentration difficulties you experience?

What are the main organisation, planning, or time-management difficulties?

Do you experience restlessness, impulsivity, or difficulty slowing down?

When did you first notice these difficulties?

Step 3 of 6 — Impact

Impact on life

Tell us where these difficulties affect you most.

Please describe the impact in more detail

Step 4 of 6 — Childhood

Childhood history

ADHD symptoms usually begin in childhood. Please share what you remember.

Do you recall similar difficulties during childhood?

Please describe any childhood examples

Were there any school-related difficulties?

Step 5 of 6 — Additional context

Additional information

Have you previously received any diagnosis or support?

Do you have any current mental health concerns?

Anything else you would like the clinician to know?

Step 6 of 6 — Consent

Final details

I confirm that the information provided is accurate to the best of my knowledge and I consent to this information being reviewed by Dr Musa Sami’s clinical team.

Submitting your report...

ADHD Self Report

Current symptoms

Impact on life

Childhood history

Additional information

Final details

Combo Park, Rear of 6 Bulwell Lane, Nottingham, NG6 0BT, Nottingham, United Kingdom

Reach out to me, talk to me, I’m listening!

contact@drmusasami.co.uk

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