ADHD Screening Form

Please use this form if want to make an ADHD prescription request. You will also need a medication screening review – if you do not have this, then please call our receptionist to arrange a review. The receptionist will make a screening appointment with a clinician who will review your form and medical record. You may get a call from our receptionist if there is a need for further discussion.

Please do not use this form if you want to discuss ADHD or are considering starting ADHD medication; instead, call the practice to make a GP appointment.

Please be aware that the clinicians will follow NHS Lothian Shared Care Protocol for ADHD specialist medication. Click here for more information.

Last Updated: 09/01/2024

PERSONAL AND PRESCRIPTION DETAILS

What is your name? *

What is your date of birth? *

What is your mobile telephone number? *

Please type in the ADHD medication you are requesting *

Please type in which chemist you want the prescription to be sent to, or indicate if you want to collect it from the surgery. *

NHS LOTHIAN SHARED CARE PROTOCOL

Morningside Medical Practice will only continue ADHD if a patient has been stabilised on medication and it follows the NHS Lothian Shared Care Protocol. Please click here for more information.

Morningside Medical Practice will not change the dosage or regime of ADHD medications – this can only be done by an ADHD specialist who will organise the prescription and any necessary follow-up.

If a patient wishes to change their regime of medication, then we would recommend that they speak with their ADHD specialist.

I HAVE READ AND UNDERSTAND THE NHS LOTHIAN SHARED CARE PROTOCOL INFORMATION GIVEN ABOVE. (If you tick no and/or do not understand this information, then you will get a call from our receptionist to make a clinician appointment.) *

Yes No

I WISH TO HAVE A DISCUSSION ABOUT MY ADHD MEDICATION WITH A CLINICIAN FURTHER. (If you tick yes, then you will get a call from our receptionist to make a clinician appointment.) *

Yes No

I wish to continue my adhd medication. (if you tick no, then you will get a call from our receptionist to make a clinician appointment) *

Yes No

CLINICAL INFORMATION

If you have read, understand, and are happy to continue with your ADHD medication and you do not wish to discuss it further, the clinician will look at the answers you provide to the clinical information below.

The clinician may contact you to clarify information, but if the clinician is happy with your answers they will issue and send the prescription for you on the date that the receptionist organised the clinician screening review for you to the chemist that you have indicated above.

If you have asked for a further clinician discussion, or the clinician wants a further discussion, the receptionist will call you for an appointment.

Please answer the following clinical questions to aid the review:

BMI: Click here to help you calculate your BMI.

Please type in your average BP reading and when it was taken. (You can get this checked at home, in the high street chemist, or make a nurse BP appointment.) *

PLEASE TYPE IN YOUR HEART RATE (PULSE) AND WHEN IT WAS TAKEN. (YOU CAN GET THIS CHECKED AT HOME, IN THE HIGH STREET CHEMIST, OR MAKE A NURSE BP APPOINTMENT.) *

Please type in your height (cm), weight (kg), BMI (see above link to help you calculate this), and when it was taken. (You can get this checked at home, in the high street chemist, or make a nurse BP appointment.) *

DATA PROTECTION AND CONSENT

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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ADHD Screening Form

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