Adult New self-report ADHD – Schooling Assessment

Adult New self report

Please ensure all relevant documentation and reports are present before completing the form. If you have difficulty attaching and uploading reports please email these documents.

Demographic details
Completion Date
DD slash MM slash YYYY
Name*
First Last
Gender*
- Female
- Male
Date of Birth*
DD slash MM slash YYYY
Cell Phone*
Email*
Enter Email Confirm Email
Name of Contact ( In case of emergency)*
First Last
Therapists seen(i.e. psychologist etc) copy to
First Name Last Name Discipline Email

Please include all professionals previously seen or currently seeing in the course of your child's assessment. Click the + to include another
New and Follow-up consultation forms*
- New Assessment Forms( First Time)
- Follow-up Assessment forms( after 1 or 6 monthly)
New Assessment Forms( First Time)
Previous Medical History
Please include all information that you consider relevant. All information is confidential.
Problems during pregnancy*
- Medications or substances taken
- Stressor's
- Complications
- None
- Other
Please include medical as well as psychological
Other Problems during pregnancy*
Birth Weight(Kg)*
Please enter a number from 1 to 5.
Colic or Cramps in the first 3 months*
- yes
- No
Difficulty with excessive crying or sleeping problems.
Problems During Birth*
- Birth at Term
- Birth Premature
- Normal APGAR score
- Abnormal APGAR Score
- Feeding Problems
- None
- Other
Please indicate problems during, immediately after, and in the first month of life.
Other Problems During Birth*
Milestones and Development*
- All age appropriate
- Sitting/crawling/ Walking /Delayed
- Abnormal Speech or delay
- Other
Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?
Milestones Developmental*
Immunizations Up-to-Date*
- Yes
- No
Previous or current medical or surgical problems*
- Tonsillectomy
- Adenoidectomy
- Grommet insertion
- Bone Fractures
- Lacerations and sutures (" Stitches")
- Asthma
- Allergies
- None
- Other
Any chronic illnesses, operations( tonsillectomy, adenoidectomy, grommets) , hospital admissions, broken bones or serious lacerations. Allergies to medications other other.
Other medical or surgical problems*
Speech and Language Difficulties*
- Articulation( pronunciation)
- Lisp
- Stutter
- Phonics
- None
- Other
Has the teacher or other family members commented on speech or suggested speech therapy.
Other Speech and Language Difficulties*
Gross and Fine Motor Problems*
- Pencil Grip
- Colouring and Cutting
- Clumsy
- Posture
- None
- other
Sitting or standing with poor posture? Flat feet. Hyper-mobile joints? Clumsy? Does not know left and right? Pencil grip, colouring and cutting out. Letter reversals. Problems with shapes and writing.
Other Gross and Fine Motor Problems*
Sensory Integration Problems*
- Tactile (touch)
- Auditory (sound)
- Vestibular (balance)
- Olfactory (smell)
- Other
- none
Over sensitive to: labels on clothes, textures, sounds and busy environments, smells, heights or balance.
Other Sensory Integration Problems*
Hearing Test Performed*
- Yes
- No
Recent? Audiologist or at school.
Vision Test*
- Yes
- No
Recent? Optometrist or at school? Wears spectacles?
Sleeping Problems*
- Difficulty falling asleep
- Frequent waking
- Bedwetting
- Snores at night
- < 10 hours per night
- None
- Other
In the Past or current? Nightmares or fearful at night? Strict sleeping routine? Restless? Excess TV or electronic devices.
Other sleeping Problems*
Eating Problems*
- Fussy
- Overeating
- Overweight
- No
- Other
Impulsive eating leading to overeating.
Other Eating Problems*
Medications*
- Prescription
- Vitamins or Natural
- Difficulty swallowing tablets
- None
- Other
List medications or vitamins
Other medications*
Medication Dosage Frequency

List all medications and other products. Click + other multiple items.
Current or Previous Therapy received*
- Occupational
- Speech
- Remedial
- Psychological
- Homeopathic
- Neurofeedback
- Behavior Optometry
- None
- Other
Currently or previously. Please indicate duration and name of therapist
Other therapy received*
Parental Concerns
Behavior Problems*
- Outbursts
- Defiant
- Oppositional
- Physical conflicts
- Home
- School
- None
- Other
Include concerns experienced at school and outside of school frequently.
Other behaviour problems*
Bed-wetting or soiling*
- Bed-wetting
- Soiling
- No
- Other
Other Bed-wetting or soiling problems*
Organisational Skills*
- Good
- Average
- Poor (Needs constant Supervision)
- Morning Routine Problematic
- Afternoon Routine Problematic
- Evening Routine Problematic
- Other
Indicate problems that occur daily or weekly requiring frequent attention.
Other Organisational problems*
Emotional and Social Problems( at school and home)*
- Many friends ( Gregarious) sustains friendships
- Few Friends. Cannot sustain friendships.
- Mood has significant daily impact at home
- Mood has significant daily impact at school
- Socially withdrawn.
- Problems with Siblings
- None
- Other
Other Emotional and Social Problems*
FAMILY HISTORY
Siblings' Names and Ages
Name Age (years) Biological or step-sibling

Click +for more than one. Under 'Other' indicate if does not live in the same household.
Family Structure*
- Family Intact
- Divorced
History of A.D.H.D or Learning Problems*
- Father with ADHD
- Mother with ADHD
- Sibling with ADHD
- Relative with ADHD
- Learning problems
- Matric not completed.
- None
- Other
Indicate if either parent or immediate family required additional or remedial assistance at school. Repeated a grade. Dyslexia? Spelling problems? Behavioural Problems? Matric not completed
Other History of A.D.H.D or Learning Problems*
Family Medical History*
- Heart problems as a child
- Depression or anxiety
- Motor Tics or Tourettes (nervous twitches)
- Epilepsy
- None
- Other
Other Family Medical History*
SCHOOLING HISTORY
Therapy at school or after-school*
- Remedial
- OT
- Speech therapy
- Psychological or Play therapy
- None
- Other or Current therapy
Indicate if received additional therapy at school by Occupational therapist(OT), Speech therapist, Remedial teacher. Behavioural therapy by Psychologist.
Other or Therapy at school*
Pre-School Problems*
- Concentration
- Behaviour and Emotional
- Task completion
- Learning
- None
- Other
Indicate if teachers were concerned
Other Pre-School Problems*
Junior School Problems*
- Concentration
- Behaviour and Emotional
- Task completion
- Learning
- None
- Other
Indicate if teachers were concerned
Other Junior School Problems*
High School Problems*
- Concentration
- Behaviour and Emotional
- Task completion
- Learning
- none
- Other
Indicate if teachers were concerned
Other High School Problems*
ASSESSMENTS COMPLETED
Include all assessments by therapists and relevant reports.
ASSESSMENTS COMPLETED and relevant reports
Drop files here or

Accepted file types: jpg, pdf, gif, png, Max. file size: 12 GB.
The more information received before the assessment ensures more time assessing your child during the consultation.
Therapist Assessment*
- Educational Assessment
- Occupational Therapist Assessment
- Remedial Teacher Assessment
- Speech Therapist Assessment
- Clinical or Counselling Psychologist Assessment
- Other
Currently or previously.
Other Therapist Assessment*
Educational Assessment NON-VERBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Educational Assessment VERBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Educational Assessment GLOBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Additional information you wish to include
Questionnaire
FAMILY
1. Having problems with family*
- Never
- Occasionally
- Often
- Very Often
- N/A
2. Having problems with spouse/partner*
- Never
- Occasionally
- Often
- Very Often
- N/A
3. Relying on others to do things for you*
- Never
- Occasionally
- Often
- Very Often
- N/A
4. Causing fighting in the family*
- Never
- Occasionally
- Often
- Very Often
- N/A
5. Makes it hard for the family to have fun together*
- Never
- Occasionally
- Often
- Very Often
- N/A
6.Problems taking care of your family*
- Never
- Occasionally
- Often
- Very Often
- N/A
7. Problems balancing your needs against those of your family*
- Never
- Occasionally
- Often
- Very Often
- N/A
8. Problems losing control with family*
- Never
- Occasionally
- Often
- Very Often
- N/A
WORK
9. Problems performing required duties*
- Never
- Occasionally
- Often
- Very Often
- N/A
10. Problems with getting your work done efficiently*
- Never
- Occasionally
- Often
- Very Often
- N/A
11. Problems with your supervisor*
- Never
- Occasionally
- Often
- Very Often
- N/A
12. Problems keeping a job*
- Never
- Occasionally
- Often
- Very Often
- N/A
13. Getting fired from work*
- Never
- Occasionally
- Often
- Very Often
- N/A
14. Problems working in a team*
- Never
- Occasionally
- Often
- Very Often
- N/A
15. Problems with your attendance*
- Never
- Occasionally
- Often
- Very Often
- N/A
16. Problems with being late*
- Never
- Occasionally
- Often
- Very Often
- N/A
17. Problems taking on new tasks*
- Never
- Occasionally
- Often
- Very Often
- N/A
18. Problems working to your potential*
- Never
- Occasionally
- Often
- Very Often
- N/A
19. Poor performance evaluations*
- Never
- Occasionally
- Often
- Very Often
- N/A
20. Problems taking notes*
- Never
- Occasionally
- Often
- Very Often
- N/A
21. Problems completing assignments*
- Never
- Occasionally
- Often
- Very Often
- N/A
22. Problems getting your work done efficiently*
- Never
- Occasionally
- Often
- Very Often
- N/A
23. Problems with teachers*
- Never
- Occasionally
- Often
- Very Often
- N/A
24. Problems with school administrators*
- Never
- Occasionally
- Often
- Very Often
- N/A
25.Problems meeting minimum requirements to stay in school*
- Never
- Occasionally
- Often
- Very Often
- N/A
26. Problems with attendance*
- Never
- Occasionally
- Often
- Very Often
- N/A
27. Problems with being late*
- Never
- Occasionally
- Often
- Very Often
- N/A
28. Problems with working to your potential*
- Never
- Occasionally
- Often
- Very Often
- N/A
29.Problems with inconsistent grades*
- Never
- Occasionally
- Often
- Very Often
- N/A
LIFE SKILLS
1 . Excessive or inappropriate use of internet, video games or TV*
- Never
- Occasionally
- Often
- Very Often
- N/A
2. Problems keeping an acceptable appearance*
- Never
- Occasionally
- Often
- Very Often
- N/A
3. Problems getting ready to leave the house*
- Never
- Occasionally
- Often
- Very Often
- N/A
4. Problems getting to bed*
- Never
- Occasionally
- Often
- Very Often
- N/A
5. Problems with nutrition*
- Never
- Occasionally
- Often
- Very Often
- N/A
6. Problems with sex*
- Never
- Occasionally
- Often
- Very Often
- N/A
7. Problems with sleeping*
- Never
- Occasionally
- Often
- Very Often
- N/A
8. Getting hurt or injured*
- Never
- Occasionally
- Often
- Very Often
- N/A
9. Avoiding exercise*
- Never
- Occasionally
- Often
- Very Often
- N/A
10. Problems keeping regular appointments with doctor/dentist*
- Never
- Occasionally
- Often
- Very Often
- N/A
11 .Problems keeping up with household chores*
- Never
- Occasionally
- Often
- Very Often
- N/A
12. Problems managing money*
- Never
- Occasionally
- Often
- Very Often
- N/A
SELF-CONCEPT
1. Feeling bad about yourself*
- Never
- Occasionally
- Often
- Very Often
- N/A
2 .Feeling frustrated with yourself*
- Never
- Occasionally
- Often
- Very Often
- N/A
3. Feeling discouraged*
- Never
- Occasionally
- Often
- Very Often
- N/A
4. Not feeling happy with your life*
- Never
- Occasionally
- Often
- Very Often
- N/A
5. Feeling incompetent*
- Never
- Occasionally
- Often
- Very Often
- N/A
SOCIAL
1. Getting into arguments*
- Never
- Occasionally
- Often
- Very Often
- N/A
2. Trouble cooperating*
- Never
- Occasionally
- Often
- Very Often
- N/A
3. Trouble getting along with people*
- Never
- Occasionally
- Often
- Very Often
- N/A
4.Problems having fun with other people*
- Never
- Occasionally
- Often
- Very Often
- N/A
5. Problems participating in hobbies*
- Never
- Occasionally
- Often
- Very Often
- N/A
6. Problems making friends*
- Never
- Occasionally
- Often
- Very Often
- N/A
7. Problems keeping friends*
- Never
- Occasionally
- Often
- Very Often
- N/A
8. Saying inappropriate things*
- Never
- Occasionally
- Often
- Very Often
- N/A
9. Complaints from neighbours*
- Never
- Occasionally
- Often
- Very Often
- N/A
RISK
1. Aggressive driving*
- Never
- Occasionally
- Often
- Very Often
- N/A
2 .Doing other things while driving*
- Never
- Occasionally
- Often
- Very Often
- N/A
3. Road rage*
- Never
- Occasionally
- Often
- Very Often
- N/A
4. Breaking or damaging things*
- Never
- Occasionally
- Often
- Very Often
- N/A
5. Doing things that are illegal*
- Never
- Occasionally
- Often
- Very Often
- N/A
6. Being involved with the police*
- Never
- Occasionally
- Often
- Very Often
- N/A
7. Smoking cigarettes*
- Never
- Occasionally
- Often
- Very Often
- N/A
8. Smoking marijuana*
- Never
- Occasionally
- Often
- Very Often
- N/A
9. Drinking alcohol*
- Never
- Occasionally
- Often
- Very Often
- N/A
10. Taking "street" drugs*
- Never
- Occasionally
- Often
- Very Often
- N/A
11. Sex without protection (birth control, condom)*
- Never
- Occasionally
- Often
- Very Often
- N/A
12. Sexually inappropriate behaviour*
- Never
- Occasionally
- Often
- Very Often
- N/A
13. Being physically aggressive*
- Never
- Occasionally
- Often
- Very Often
- N/A
14. Being verbally aggressive*
- Never
- Occasionally
- Often
- Very Often
- N/A
31. Is physically cruel to people*
- Never
- Occasionally
- Often
- Very Often
32. Has stolen things that have value*
- Never
- Occasionally
- Often
- Very Often
33. Deliberately destroys others’ property*
- Never
- Occasionally
- Often
- Very Often
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)*
- Never
- Occasionally
- Often
- Very Often
35. Is physically cruel to animals*
- Never
- Occasionally
- Often
- Very Often
36. Has deliberately set fires to cause damage*
- Never
- Occasionally
- Often
- Very Often
37. Has broken into someone else’s home, business, or car*
- Never
- Occasionally
- Often
- Very Often
38. Has stayed out at night without permission*
- Never
- Occasionally
- Often
- Very Often
39. Has run away from home overnight*
- Never
- Occasionally
- Often
- Very Often
40. Has forced someone into sexual activity*
- Never
- Occasionally
- Often
- Very Often
41. Is fearful, anxious, or worried*
- Never
- Occasionally
- Often
- Very Often
42. Is afraid to try new things for fear of making mistakes*
- Never
- Occasionally
- Often
- Very Often
43. Feels worthless or inferior*
- Never
- Occasionally
- Often
- Very Often
44. Blames self for problems, feels guilty*
- Never
- Occasionally
- Often
- Very Often
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”*
- Never
- Occasionally
- Often
- Very Often
46. Is sad, unhappy, or depressed*
- Never
- Occasionally
- Often
- Very Often
47. Is self-conscious or easily embarrassed*
- Never
- Occasionally
- Often
- Very Often
48. Overall school performance*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
49. Reading*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
50. Writing*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
51. Mathematics*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
52. Relationship with parents*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
53. Relationship with siblings*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
54. Relationship with peers*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
55. Participation in organized activities (eg, teams)*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
Follow-up Assessment forms( after 1 or 6 monthly)
1. Does not pay attention to details or makes careless mistakes with, for example, homework*
- Never
- Occasionally
- Often
- Very Often
2. Has difficulty keeping attention to what needs to be done*
- Never
- Occasionally
- Often
- Very Often
3. Does not seem to listen when spoken to directly*
- Never
- Occasionally
- Often
- Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)*
- Never
- Occasionally
- Often
- Very Often
5. Has difficulty organizing tasks and activities*
- Never
- Occasionally
- Often
- Very Often
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort*
- Never
- Occasionally
- Often
- Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)*
- Never
- Occasionally
- Often
- Very Often
8. Is easily distracted by noises or other stimuli*
- Never
- Occasionally
- Often
- Very Often
9. Is forgetful in daily activities*
- Never
- Occasionally
- Often
- Very Often
10. Fidgets with hands or feet or squirms in seat*
- Never
- Occasionally
- Often
- Very Often
11. Leaves seat when remaining seated is expected*
- Never
- Occasionally
- Often
- Very Often
12. Runs about or climbs too much when remaining seated is expected*
- Never
- Occasionally
- Often
- Very Often
13. Has difficulty playing or beginning quiet play activities*
- Never
- Occasionally
- Often
- Very Often
14. Is “on the go” or often acts as if “driven by a motor”*
- Never
- Occasionally
- Often
- Very Often
15. Talks too much*
- Never
- Occasionally
- Often
- Very Often
16. Blurts out answers before questions have been completed*
- Never
- Occasionally
- Often
- Very Often
17. Has difficulty waiting his or her turn*
- Never
- Occasionally
- Often
- Very Often
18. Interrupts or intrudes in on others conversations and/or activities*
- Never
- Occasionally
- Often
- Very Often
I give permission to Dr. Flett to send a medical report to the school and health care role player involved my child's management*
- Yes
- No
To maximise the treatment of your child, communication between all roll players involved in your child's management is vital.
CURRENT MEDICATIONS*
Name of medication, dose of each tablet, total dose per day List all current medications here:
Medication Dosage per tablet Dosage Morning Dosage school Dosage Afternoon Dosage daily Weekends
ADHD Symptom Control*
Please tick any changes that have occurred since taking the current medication below
Much better(+3) Moderately better(+2) Slightly better(+1) Unchanged(0) Slightly worse(-1) Moderately worse(-2) Much worse(-3)
Tolerability of Medication (side effects)*
Please tick any changes that have occurred since taking the current medication below
Much better(+3) Moderately better(+2) Slightly better(+1) Unchanged(0) Slightly worse(-1) Moderately worse(-2) Much worse(-3)
Quality of Life*
Please tick any changes that have occurred since taking the current medication below
Much better(+3) Moderately better(+2) Slightly better(+1) Unchanged(0) Slightly worse(-1) Moderately worse(-2) Much worse(-3)
How would you rate the global changes that have occurred since medication started?*
Please tick any changes that have occurred since taking the current medication below
Marked improvement Small improvement No change Small deterioration Marked deterioration Not applicable (medication not taken)
Comments

Please tick the frequency of any side effects experienced with the current treatment since your last medical appointment. Contact me if side effects are significant

	Not at all	Sometimes	Often	All the time
Appetite reduction
Weight loss
Weight gain
Stomach aches
Nausea
Vomiting
Diarrhoea
Dryness (skin/ eyes/ mouth)
Thirst
Sore throat
Sleep difficulties
Tics
Headache
Muscular tensions
Fatigue
Dizziness
Sweating
Agitation/excitability
Irritability
Mood instability
Over focus "zombie effect"
Sadness
Heart palpitations
Frequent urination
Feeling worse or different when the medication wears off (rebound)

Items to discuss at the next medical appointment

Brief outline of questions to ask at appointment

First Name	Last Name	Discipline	Email

Medication	Dosage	Frequency

Name	Age (years)	Biological or step-sibling

Medication	Dosage per tablet	Dosage Morning	Dosage school	Dosage Afternoon	Dosage daily Weekends

Adult New self report

Demographic details

New Assessment Forms( First Time)

Previous Medical History

Parental Concerns

FAMILY HISTORY

SCHOOLING HISTORY

ASSESSMENTS COMPLETED

Questionnaire

FAMILY

WORK

LIFE SKILLS

SELF-CONCEPT

SOCIAL

RISK

Follow-up Assessment forms( after 1 or 6 monthly)