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Richard Senyszyn MD
ADHD Medication Management Plan
Date: __________________________________________ To the family of __________________________________________ , please refer to this plan between visits if you have questions about care. If you are stil unsure, cal us at _______________________ for assistance. Patient _____________________________________ 's doctor is ________________________________________ Pager # __________________________________ Parent/Guardian ______________________________________________ Relationship _____________________ Contact Number(s) ____________________________________________________________________________ School Name _________________________________________________________________________________ School Phone # __________________________ Fax # __________________________ Key Teacher Contact Name _________________________________________________ Grade _______________ Teacher's E-mail Address ________________________________________________________________________ Goals What improvements would you most like to see? Specific behavior you would like to see improve:
1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ Plans to reach these goals:
1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ Richard Senyszyn MD

Medication
1. _______________________ Time __________ am/pm Time __________am/pm
2. _______________________ Time __________ am/pm Time __________am/pm
☐ Medication to be given on nonschool days
☐ School authorization signed by parent and MD
☐ Side effects explained/information given
☐ Medication given for _______ number of days
☐ RX written for duplicate bottle for administration at school
Common Side Effects: Decreased appetite, sleep problems, transient stomachache, transient headache, behavioral rebound;
atomoxetine (Strattera): sediation or insomnia, stomach upset, slight increase in blood pressure; alpha-2 agonists (lntuniv,
Kapray): sedation or drowsiness, dry mouth, decreased appetite, rebound hypertension
Call your doctor Immediately If any Infrequent side effects occur: Weight loss, increased heart rate and/or blood pressure,
dizziness, growth suppression, hallucinations/mania, exacerbation of tics and Tourette syndrome (rare); atomoxetine
(Strattera): liver failure (rare), suicidal thoughts Further Evaluation
☐ School testing scheduled
Date _______________________________________________________ Completed __________________________________________________ Additional Resources and Treatment Strategies
☐ Follow-up Parent Vanderbilt given
Completed __________________________________________________ ☐ Follow-up Teacher Vanderbilt given to parent ☐ Follow-up Teacher Vanderbilt faxed to school Completed _______ ☐ Behavioral modification counseling referral to ______________________________________________________ ☐ Parenting tips sheet given ☐ CHADD phone number given: 800/233-4050 ☐ Community resources/referrals: _________________________________________________________________ __________________________________________________________________________________________ Next Follow-up Visit: ___________________________________________________________________________

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