LOCKSIDE MEDICAL CENTRE

85 Huddersfield Road, Stalybridge SK15 2PT

Telephone: 0161 303 7200

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ADHD Assessment

Adult ADHD Referral information

Please complete this form if you think you have ADHD and would like to be referred for an assessment. This form is for people registered at Lockside Medical Centre who are age 18+. We need quite a lot of information for the referral. You will need to have recorded 3 blood pressure readings as well as your heart rate, height in centimetres and weight in kilograms. It is sensible to get these readings ready before starting the form. If you don't have access to equipment to record this, you could use the machines in our waiting room. In Greater Manchester (GM) all referrals have to be sent by GP Practices to a central service. As waiting times are long, GM will be reviewing providers and, if CQC accredited, may suggest a private providers if the waiting time is shorter. However Lockside has no influence over this. We are aware some private providers are suggesting GP Practices can refer directly to them under the Right to Choose process. This is not currently the case in Greater Manchester, but the pathways are currently under review.

About you

Name(Required)
DD slash MM slash YYYY
Gender(Required)
You may select more than one if applicable
Address(Required)
Are you experiencing any of these symptoms currently?(Required)
Please tick any that apply and use the free text box below to give more detail on any boxes you have ticked. If you are experiencing suicidal thoughts or self harm and are not already in receipt of support, please phone 0800 014 9995.

Adult ADHD Self Report Scale

Medical Information

Current physical symptoms(Required)
Sometimes people with ADHD are prescribed stimulants. The assessment service asks us for information about physical symptoms to check these are safe for you.
Family history(Required)
Please tick any that apply
Past medication(Required)
Please tick any that apply and give more details in the box below.
Please enter a number from 140 to 230.
Please enter a number from 35 to 150.

Blood pressure and heart rate

The assessment service asks us to submit 3 blood pressure readings and heart rates taken over at least 1 week. If you don't have access to a blood pressure machine then please use the one in our waiting room.
Please include the date of the reading
Please include the date of the reading
Please include the date of the reading
Please include the date of the reading
Please include the date of the reading
Please include the date of the reading
This field is for validation purposes and should be left unchanged.