Medical Exception ADD/ ADHD

__________________________________ ________________
(Patient Name) (Date of Birth)

___________________________________________________________________________________________________
(Primary Care Physician Name) (Address, City, State) (Phone number)

__________________________________ is under my care for treatment of ADD/ ADHD since ___________
(Patient’s Name) (Date of initial TX)

Dr. Completes

YES NO Alternative non-stimulant medication use has been considered, or tried with unsatisfactory clinical results. LIST those tried, if applicable______________________________________________________________

The current medication and dosage is ______________________________________________________ Reason for this medication: ______________________________________________________________

YES NO An accepted ADHD rating scale was used to make the diagnosis. If NO, how was the course of treatment determined? (Attach any clinical SOAP notes)

YES NO CONNER”S Adult ADHD reporting scales (CAARS)

YES NO ASRS (Adult ADHD self report scale)

Other: __________________________________________________________________

** Please submit copies of test results for the athlete’s college