ADHD Medication History Form

The ADHD Medication History Form collects essential information to ensure safe and effective treatment. It includes personal details, medical history, and current and past ADHD medications to support treatment planning. The form also covers lifestyle factors such as sleep, diet, and exercise, as well as any previous behavioural interventions like CBT. A monitoring section helps track vital signs over four weeks. Patients can provide consent for sharing medical information, and the form includes a declaration acknowledging the importance of regular health checks and data protection compliance. Reasonable Adjustments for Medication Management In accordance with the Equality Act 2010, reasonable adjustments will be made to support individuals who may experience challenges with medication management due to disabilities, learning differences, or health conditions. The adjustments aim to ensure safe, effective, and accessible medication adherence while promoting independence and well-being. Accessible Information We are committed to ensuring that information is accessible to all individuals. If you require this document in an alternative format, please let us know so we can meet your needs. Consent to Treatment and Right to Refuse By engaging with BrightPath Assessment services, you acknowledge and provide informed consent for assessment, diagnosis, and treatment based on your individual clinical needs.

Consent to Treatment:

  • You have the right to receive clear, accurate, and relevant information regarding your diagnosis, treatment options, potential risks, and expected outcomes.

  • Your consent is required before any treatment is initiated, and you have the opportunity to ask questions and discuss any concerns with your clinician.

  • Treatment plans are tailored to your individual needs and are subject to ongoing review and adjustment as necessary.

  • You may be asked to provide written consent for certain treatments or procedures to ensure mutual understanding and agreement.

  • Participation in treatment is voluntary, and you are encouraged to be actively involved in decisions regarding your care.

Right to Refuse Treatment:

  • You have the right to refuse any aspect of the proposed treatment plan, including medication, therapy, or diagnostic procedures.

  • If you choose to refuse treatment, your decision will be respected, and you will be informed of the potential consequences and risks associated with that choice.

  • Refusal of treatment may impact your ability to continue receiving services, particularly if it poses a risk to your health or well-being.

  • If you wish to withdraw consent at any time, you must notify your clinician in writing, and alternative support options will be discussed where possible.

  • Brightpath Assessment reserves the right to discontinue services if refusal of treatment compromises the ability to provide safe and effective care.

Your informed participation and collaboration in your treatment journey are essential to achieving the best possible outcomes. If you have any questions or require further clarification, please contact our team.

Personal Information

Please provide accurate personal details to help us identify you and contact you if necessary.

Next of Kin (NOK) Details

Next of kin relationship to you (e.g. partner, mother, sister, brother, aunty, friend etc.)
Next of kin email
Next of kin phone number

Prescription Delivery Preference

Please let us know your preferred pharmacy or delivery location for your prescriptions. This will help us ensure that your medication is sent to the most convenient and accessible location for you. If you require assistance in selecting a pharmacy or have any concerns regarding your medication delivery, please do not hesitate to contact us.

Pharmacy name
Please put the address details of your usual pharmacy you collect prescriptions from
Country
(e.g.,home delivery preferences, collection times, etc.)

Medical History

Please provide details about your medical history, including any known conditions and medications. This helps us ensure your safety during treatment.

1. Any diagnosed medical conditions (e.g., diabetes, asthma, epilepsy, mental health conditions) 2. Previous surgeries or hospitalisations, 3. Chronic illnesses or ongoing treatments
1. Current medications, including prescription, over the counter, and supplements, 2. Any known allergies or adverse reactions to medications, 3. Past medications that have been ineffective or caused side effects
1. Any hereditary conditions (e.g., heart disease, diabetes, cancer, neurological disorders), 2. Significant illnesses within immediate family members (stroke, sudden cardiac events, genetic conditions affecting the heart (e.g., cardiomyopathy)
1. Any diagnosed heart conditions (e.g., hypertension, arrhythmias, heart disease), 2. Previous heart-related procedures or surgeries (e.g., stents, bypass surgery), 3. History of high blood pressure or cholesterol, 4. Symptoms such as chest pain, palpitations, shortness of breath, or dizziness

Liver Function History

1. Any diagnosed liver disorders (e.g., fatty liver disease, hepatitis, cirrhosis, liver enzyme abnormalities) 2. Previous liver function test results, including elevated liver enzymes (ALT, AST, ALP, bilirubin) 3. History of jaundice, liver infections, or inflammation 4. Symptoms such as fatigue, nausea, abdominal pain, or yellowing of the skin/eyes
1. Frequency and quantity of alcohol consumption, 2. History of substance use, including medications that may affect liver function (e.g., acetaminophen, statins, herbal supplements)
1. Current and past use of medications that may impact liver function, 2. Use of herbal supplements or alternative treatments that can affect liver health
1. Any hereditary liver conditions (e.g., hemochromatosis, Wilson’s disease) 2. Significant liver-related illnesses in close family members

Kidney Function History

1. Chronic kidney disease (CKD), kidney stones, infections, or any other diagnosed conditions. 2. Previous test results indicating abnormal kidney function (e.g., elevated creatinine, reduced GFR).
Include any symptoms experienced, for example: Swelling in the legs, fatigue, changes in urination frequency, or persistent lower back pain.
1. Use of medications that may affect kidney function (e.g., NSAIDs, diuretics). 2. Any previous treatments or interventions related to kidney health.
1. Any hereditary kidney conditions in immediate family members.
1. Hydration habits, dietary choices, and any history of high blood pressure or diabetes that could impact kidney function.

Allergies

Please inform us of any allergies that you have and the symptoms those allergies cause

1. Medications (e.g., penicillin, aspirin, etc.) 2. Food (e.g., nuts, dairy, gluten) 3. Environmental (e.g., pollen, dust, pet dander) 4. Other substances (e.g., latex, chemicals, etc.)

Current Medications

Please include medication that prescribed and/or is purchased over the counter, including herbal remedies.

1. Include name of medication, 2. include dose & frequency, 3. include what this is prescribed/used for

Mental Health History

Please list this history in chronological order, starting from early years.

1. Depression, anxiety, ADHD, autism spectrum disorder (ASD), bipolar disorder, schizophrenia, OCD, PTSD, or other conditions. 2. Date of diagnosis and the healthcare professional who provided it.
Mood changes, difficulty concentrating, intrusive thoughts, panic attacks, sleep disturbances, or other concerns.
1. Current or past medications (e.g., antidepressants, mood stabilizers, stimulants, etc.) 2. Previous therapy or counselling (e.g., CBT, DBT, psychoeducation, etc.) 3. Hospitalisations or crisis interventions, if applicable.
1. Effects on work, relationships, and daily functioning. 2. Coping strategies currently in use.
Any history of mental health conditions within close family members.

Monitoring Vital Signs

Please monitor your vital signs once a week over the next four weeks, aiming to do so on the same day and at the same time each week for consistency. This box should have four recordings for each observation.

Lifestyle Factors

Provide information on your lifestyle habits, including sleep patterns, diet, exercise, and substance use, as they may impact your treatment plan.

1. Sleep Onset: How long does it take to fall asleep? 2. Sleep Duration: How many hours of sleep are you getting each night? 3. Sleep Quality: Do you experience restless sleep, frequent awakenings, or feel refreshed in the morning? 4. Medication Effects: Have you noticed any changes in your sleep patterns since starting or adjusting medication? 5. Routine Consistency: Are you maintaining a regular sleep schedule
1. Meal Patterns: Are you eating regular meals and snacks throughout the day? 2. Appetite Changes: Have you noticed any changes in hunger levels since starting or adjusting medication? 3. Food Choices: Are you consuming a balanced diet, including fruits, vegetables, proteins, and whole grains? 4. Hydration: Are you drinking enough water throughout the day? 5. Medication Effects: Does your medication impact your appetite, leading to skipped meals or overeating later?
1. Alcohol Consumption: How often and how much alcohol do you consume? 2. Caffeine Intake: Are you consuming energy drinks, coffee, or other caffeinated beverages that may affect sleep or medication effectiveness? 3. Nicotine Use: Do you smoke or use nicotine products, such as vaping or chewing tobacco? 4. Recreational Drugs: Have you used any recreational drugs that could interfere with your treatment plan? 5. Medication Interactions: Are you taking any over-the-counter supplements, herbal remedies, or other prescribed medications that could affect your ADHD medication?

Behavioural Interventions

If you have ticked any of the above, please provide more information here.

Consent to Share Information

If you have ticked other, please specify here.
Please provide the names, phone numbers and the emails of the individuals you consent to share your information with. - We will only communicate and share information with the family members listed above if you have given us permission to do so.

Medical Health Declaration

Please read and acknowledge the medical health declaration, which outlines the necessary health checks required before and during medication treatment.

I confirm that the information provided regarding my medical and medication history is accurate and complete to the best of my knowledge. This includes all current and past medical conditions, prescription medications, over-the-counter treatments, herbal supplements, and any known allergies or adverse reactions. I understand the importance of this information in ensuring safe and effective care and acknowledge my responsibility to inform my healthcare provider of any changes to my health or medication regimen. As part of this process, my vital signs will be monitored for a total of four weeks to assess my response to treatment and ensure my well-being.

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Medication Fees 

We believe in transparency and providing clear information about our services and associated costs. Our price list outlines the fees for our range of services to ensure you have a full understanding of what to expect.

Key Information Included in Our Price List:

  • A detailed breakdown of services offered

  • Pricing for assessments, consultations, and follow-up support

  • Any additional costs for optional services or reports

  • Payment methods and available plans

  • Cancellation and refund policies

  • Our pricing is designed to be competitive while ensuring the highest quality of care and professionalism.

For the most up-to-date price list or to discuss specific requirements, please contact our team directly. We are happy to provide further details and assist you in choosing the services that best meet your needs.

Pre-Health Assessment – One-Time Fee of £250

Our Full Health MOT offers a comprehensive assessment of your overall well-being, providing valuable insights into your cardiovascular, metabolic, and general health status. This package is designed to empower you with the tools and knowledge needed to monitor your health effectively and make informed decisions about your lifestyle and medical care. All necessary equipment is included, allowing you to take control of your health both now and in the future.

Blood Pressure Monitoring:

  • Receive an electronic blood pressure machine to monitor your readings.

  • The device is yours to keep for long-term health management.

ECG Monitoring:

  • A 6-lead KardiaMobile ECG machine is provided, also yours to keep.

  • Enables continuous monitoring of your heart’s electrical activity to ensure medication safety.

Cardiovascular Risk Calculation:

  • A 10-year risk assessment for heart disease to identify potential health concerns early.

Height and Weight Measurements:

  • Used to calculate your BMI (Body Mass Index), a critical factor in safe prescribing practices.

Lifestyle Recommendations:

  • Personalised advice based on your health results to support overall well-being.

Our Commitment to Your Safety

Our Full Health MOT ensures that your treatment is both safe and effective. By providing key health monitoring devices and a personalised approach, we offer excellent value compared to other providers.

Take the first step toward better health and peace of mind—schedule your Health check today!

Prescribing Fee: £150 Per 60-Minute Review
We offer a transparent and affordable prescribing fee of £150 per 60-minute review appointment.

What’s Included in Your Appointment?

Discussion of Medication Options:

  • Clear explanations of the best treatment options to meet your needs.

Prescribing and Titration:

  • Safe initiation and adjustment of your medication to achieve optimal results.

Regular Monitoring and Feedback:

  • Ongoing review of your progress and necessary adjustments for treatment effectiveness.

Please note: This fee covers health assessment only and does not include the cost of medication, as prescriptions are issued privately. For medication pricing, please consult your provider.

Stabilisation and Shared Care Agreement

Our objective is to stabilise your medication regimen for at least six months before arranging a shared care agreement with your GP. However, please note:

  • GPs are not obligated to accept shared care agreements.

  • If your GP declines, we will continue to provide ongoing prescribing and monitoring services as needed.

Terms and Conditions for Medication Treatment with Brightpath Assessment

1. Introduction

1.1 These Terms and Conditions ("T&Cs") govern the provision of medication treatment services provided by Brightpath Assessment.
1.2 By using our services, you agree to comply with and be bound by these T&Cs.

2. Eligibility for Services

2.1 Our medication treatment services are available to individuals following a comprehensive assessment conducted by Brightpath Assessment clinicians.
2.2 Services are provided in accordance with UK healthcare regulations and best clinical practices.
2.3 We reserve the right to refuse or discontinue treatment if it is deemed clinically inappropriate.

3. Assessment and Treatment Plan

3.1 A thorough clinical assessment must be completed before any medication is prescribed.
3.2 Treatment plans are personalized based on the assessment findings and medical history provided.
3.3 You are required to provide accurate and up-to-date medical information to ensure safe and effective treatment.
3.4 Behavioral interventions should continue alongside medication to support long-term management and overall well-being.

4. Prescription Policy

4.1 Medications are prescribed based on clinical need and evidence-based guidelines.
4.2 Repeat prescriptions are subject to regular review and monitoring appointments.
4.3 Brightpath Assessment reserves the right to refuse a prescription if there are concerns about misuse, dependency, or adverse effects.
4.4 Patients must collect their prescriptions within 28 days; otherwise, the prescription will be void, and a new request will be required.
4.5 A replacement fee will apply for lost or damaged prescriptions.
4.6 A minimum of 7 days' notice is required for repeat prescriptions. It is the patient's responsibility to ensure timely requests.
4.7 It is your responsibility to arrange follow-up appointments to continue receiving prescriptions and treatment.

5. Monitoring and Follow-Up

5.1 Ongoing monitoring appointments are mandatory to assess treatment effectiveness and side effects.
5.2 Any changes in your health condition or medication-related side effects must be reported to your clinician promptly.
5.3 Failure to attend follow-up appointments may result in the discontinuation of medication.

6. Fees and Payment

6.1 Fees for assessment and treatment services will be clearly outlined before service commencement.
6.2 Payments must be made in full prior to consultations, unless otherwise agreed in writing.
6.3 Failure to make payments may result in suspension of services.

7. Cancellations and Refunds

7.1 Cancellations must be made at least 48 hours in advance. Failure to do so may result in a cancellation fee.
7.2 Refunds will only be issued in accordance with our refund policy, which is available upon request.

8. Confidentiality and Data Protection

8.1 All personal and medical data are handled in accordance with the UK Data Protection Act 2018 and GDPR regulations.
8.2 Information will only be shared with third parties with your explicit consent or as required by law.

9. Patient Responsibilities

9.1 Patients must adhere to the prescribed treatment plan and attend all scheduled appointments.
9.2 It is the patient's responsibility to inform Brightpath Assessment of any changes in their health status.
9.3 Misuse or sharing of prescribed medication is strictly prohibited and may result in service termination.

10. Complaints and Feedback

10.1 If you are dissatisfied with any aspect of our service, you may submit a formal complaint in writing.
10.2 Complaints will be handled in line with our complaints procedure, available upon request.

11. Limitation of Liability

11.1 Brightpath Assessment shall not be held liable for any adverse effects resulting from non-compliance with treatment recommendations.
11.2 We do not guarantee specific outcomes from the treatment provided.

12. Amendments to Terms

12.1 Brightpath Assessment reserves the right to modify these T&Cs at any time.
12.2 Continued use of our services following any updates constitutes acceptance of the revised terms.

13. Governing Law

13.1 These T&Cs are governed by the laws of England and Wales.
13.2 Any disputes arising shall be subject to the exclusive jurisdiction of the courts of England and Wales.

14. Removal from Service

14.1 Brightpath Assessment operates a zero-tolerance policy regarding abusive or rude behaviour towards our staff.
14.2 Any form of verbal or physical abuse, including rude or inappropriate communication, will result in immediate termination of services.
14.3 If a patient is removed from the service, they will be informed in writing, and alternative care arrangements will need to be sought independently.

Final Declaration

By signing below, you confirm that all the information provided is accurate and that your personal data will be processed in compliance with the Data Protection Act 2018.

I confirm that the information provided in this form is accurate to the best of my knowledge. I understand that my personal data will be processed in accordance with the Data Protection Act 2018.

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