ADHD Medication Adherence & Missed-Dose Planning Worksheet​

Remembering medication consistently can be difficult for adults with ADHD because the same executive-function challenges being treated—working-memory limitations, time blindness, distractibility, inconsistent routines, and difficulty transitioning between activities—can also interfere with adherence. This worksheet helps externalize the medication routine through alarms, environmental cues, organizational systems, refill planning, tracking, and a written prescriber-approved plan for what to do if a dose is late, missed, or uncertain. It does not provide medication instructions; instead, it helps patients reliably follow the individualized plan established by their prescriber or pharmacist.

Prescriber-Approved Routine • Reminders • Pill Organization • Refill Planning • Late/Missed-Dose Plan

ADHD Medication Adherence & Missed-Dose Planning Worksheet

This worksheet supports medication consistency without providing medication instructions. The goal is to externalize memory, build refill systems, and create a written prescriber-approved plan for what to do when a dose is late, missed, or uncertain.

Mark Zauss, BC-TMC, LMHC, LPC, CCMHC, NCC, ASDCS, CCTP, CCTP II, NATC, ADHD-CCSP, C-DBT, C-PD
Original psychoeducational and treatment-monitoring resource. Scores are descriptive and are not diagnostic.

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How to use: Rate each item based on your typical pattern or the past 1–2 weeks. Use repeated scores to track change over time rather than treating one score as a diagnosis.

Name / initials

Date

Assessment

Routine Consistency

0 / 20

1. I take medication according to my prescriber's instructions.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. Medication is linked to a reliable daily cue.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I do not depend on memory alone.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. My medication location is consistent and safe.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. My routine still works on weekends or schedule-change days.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Reminder System

0 / 20

1. I use alarms, apps, checklists, or another external reminder.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. The reminder requires me to confirm completion.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I have a backup reminder if I dismiss the first.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. My reminder system is simple enough that I do not ignore it.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. I review missed doses to improve the system rather than blaming myself.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Organization & Safety

0 / 20

1. I can tell whether today's dose has been taken.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. Medication is stored safely and appropriately.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I avoid transferring pills in ways that create confusion.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. I keep medication separate from unrelated supplements when needed.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. I know whom to contact if I am uncertain about a dose.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Refill Planning

0 / 20

1. I know how many days remain before medication runs out.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. I request refills early enough to avoid gaps.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I know whether controlled-medication rules affect refill timing.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. I track pharmacy/prescriber delays.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. I have a plan for travel or schedule changes.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Late / Missed Dose Planning

0 / 20

1. I have asked my prescriber what to do if I notice a dose late.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. I know when I should skip rather than take a late dose, if instructed.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I know whether food timing matters for my medication.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. I know what symptoms should prompt a call to my prescriber.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. My plan is written down rather than remembered vaguely.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Monitoring

0 / 20

1. I track benefit and side effects.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

2. I notice changes in sleep, appetite, anxiety, blood pressure, or mood when relevant.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

3. I bring adherence concerns to my prescriber honestly.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

4. I do not change dose or timing independently.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

5. I distinguish a medication problem from a routine/adherence problem.

0 Never/None

1 Rare/Mild

2 Sometimes/Moderate

3 Often/Significant

4 Very Often/Strong

Prescriber-Approved Medication Plan

Do not use this worksheet to decide independently whether to take, skip, split, repeat, or change a dose. Enter only the plan provided by the prescribing clinician or pharmacist.

Medication / prescribed schedule

Reliable cue linked to medication

If I notice the dose late, my prescriber told me to:

If I am unsure whether I already took it:

Refill trigger

Who I contact with medication questions

Scoring & AI-Style Summary

Calculate Scores

Total Score

0 / 120

Overall Burden / Skill Gap

0%

Completed Items

0 / 30

No summary generated yet.

Reflection & Next Step

What stands out most?

What is one realistic change for this week?

Clinical disclaimer: This worksheet is educational and intended to support treatment planning and self-monitoring. It does not diagnose ADHD, trauma, dissociation, attachment disorders, anxiety disorders, relationship disorders, or any other condition. Medication-related decisions must be made with the prescribing clinician.

Mark Zauss, BC-TMC, LMHC, LPC, CCMHC, NCC, ASDCS, CCTP, CCTP II, NATC, ADHD-CCSP, C-DBT, C-PD
Use results in context with clinical history, neurodevelopmental factors, trauma, sleep, mood, anxiety, relationships, medical conditions, and the client's own goals.

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