| Document Date: 2007-09-27 20:37:52
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City Reading / / IndustryTerm energy loss / / MedicalCondition conduct disorder / Sleep disturbance Major Depressive Disorder DSM-IV / Condition Reading disorder / Insomnia / ADHD / Oppositional disorder / mental retardation / mental retardation Coordination disorder DSM-IV / Phobia / mental retardation DSM-IV / depressive disorder / Panic disorder / Developmental language disorder DSM-IV / Separation anxiety disorder DSM-IV / Disorders Neurotic depression DSM-IV / language disorder / early childhood psychoses / difficulties language disorder Coordination disorder / hypersomnia / specific phobia DSM-IV / Social phobia / Disruptive Disorder / ADHD Encounter Form Learning Disorders / Separation anxiety / INTERNALIZING DISORDERS Generalized Anxiety Disorder DSM-IV / Fatigue / Tic disorder / Condition Stammering / Receptive language disorder / Learning Disabilities / Stammering / disorder / OTHER Infantile autism / Other Diagnoses Infantile autism / coordination Transient tic disorder / Restlessness / simple phobia / Generalized anxiety disorder / Neurotic depression / hyperkinetic hyperkinetic syndrome syndrome Condition Hyperkinesis / Healthcare Quality ADHD Encounter Form EXTERNALIZING DISORDERS Oppositional Defiant Disorder DSM-IV / stuttering / Psychomotor agitation / disorder DSM-IV / / MedicalTreatment psychotherapy / counseling / / Organization American Medical Association / American Academy of Pediatrics and National Initiative for Children / / Person Depressive Disorder / Gilles de la Tourette / Bereavement / / / Position Physician / Major / / ProgrammingLanguage E / /
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ADHD Encounter Form Today’s Date: ___________ Child’s Name: ________________________________________________ Age: ___________________ Sex: Male Female BD: ____________________ MR#:________________ Parent Name(s):