Intake Form for ASD

Subjective:
Chief Complaint:
Follow-up for attention and focus concerns; monitoring medication effects

History of Present Illness:
Lucas presents for follow-up regarding previously noted difficulties with attention, focus, and impulsivity in the classroom. He has been on a 40mg medication regimen, which he reports has improved his ability to focus, particularly in science. He continues to have difficulty focusing in math, which he finds uninteresting. Lucas enjoys physical education and basketball, and reports feeling more confident, especially during sports. His parents have observed increased fatigue and difficulty falling asleep despite a consistent bedtime of 9:30 PM. Appetite is decreased, with minimal intake in the morning and incomplete lunches. These symptoms are discussed as potential side effects of his current medication.

Past Medical History:
No developmental concerns are raised during the visit.

Family History:
Lucas lives with his parents, and no additional family history is provided.

Social History:
Lucas is active in sports, particularly basketball, and enjoys physical education at school. He is encouraged to use a visual checklist to support his morning routine and independence at home.

The Review of Systems:
Constitutional: Reports increased fatigue and difficulty falling asleep at night.
Gastrointestinal: Appetite is decreased, with reduced intake in the morning and incomplete lunches.
Psychiatric/Behavioral: Improved focus and confidence, especially during sports; ongoing challenges with attention in math class.

Allergies:
No known allergies reported.

Current Medications:
Lucas is currently taking 40mg of medication for attention and focus concerns.

Past Surgical History:
No past surgical history reported.

Development:
Growth parameters are noted as height in the 85th percentile and weight at an average percentile for age. No developmental concerns are raised during the visit.

Nutritional History:
Lucas's appetite is decreased, with minimal breakfast and incomplete lunches. He is advised to limit sugary drinks and consider no-sugar sparkling water as an alternative.

Objective:
Physical Examination:
Lucas's height is in the 85th percentile and his weight is at an average percentile for age. No additional physical examination findings are discussed.

Vital Signs:
Not assessed.

Investigations:
No test results discussed during this visit.

Assessment:
Problem:
1. Attention-deficit/hyperactivity disorder (314.01)
2. Medication side effects: decreased appetite and insomnia (780.52, 783.0)

Plan:
• Continue current medication regimen at 40mg.
• Monitor sleep patterns, appetite, and school performance.
• Encourage use of a visual checklist for morning routine.
• Advise limiting sugary drinks and consider no-sugar sparkling water.
• Reassess in the summer for follow-up.