Date of Request

MM

DD

YYYY

Patient Name *

First Name

Last Name

Patient DOB

MM

DD

YYYY

Patient Phone Number:

(###)

###

####

Has the patient been referred for testing based upon clinical evaluation from a Medical Professional?

If yes, please attach notes documenting this.

Yes

Now

If current testing is ADHD-related, indicate most recent results of Connors’ or similar ADHD rating scales:

Testing is not ADHD-related

Rating scales were inconclusive

Rating scales were positive

Negative

Rating scales were not administered

Have medication effects been ruled out as a cause for symptoms in question?

Yes

No

Does the member have active alcohol or substance use that would be expected to affect the validity of testing?

Yes

No