New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-768 8122 email: email@example.com
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Please include all professionals previously seen or currently seeing in the course of your child's assessment. Click the + to include another
Previous Medical History
Please include all information that you consider relevant.
All information is confidential.
Please include medical as well as psychological
Difficulty with excessive crying or sleeping problems.
Please indicate problems during, immediately after, and in the first month of life.
Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?
Any chronic illnesses, operations( tonsillectomy, adenoidectomy, grommets) , hospital admissions, broken bones or serious lacerations. Allergies to medications other other.
Has the teacher or other family members commented on speech or suggested speech therapy.
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.
Over sensitive to: labels on clothes, textures, sounds and busy environments, smells, heights or balance.
Recent? Audiologist or at school.
Recent? Optometrist or at school? Wears spectacles?
In the Past or current? Nightmares or fearful at night? Strict sleeping routine? Restless? Excess TV or electronic devices.
Impulsive eating leading to overeating.
List medications or vitamins
List all medications and other products. Click + other multiple items.
Currently or previously. Please indicate duration and name of therapist
Include concerns experienced at school and outside of school frequently.
Indicate problems that occur daily or weekly requiring frequent attention.
Click +for more than one. Under 'Other' indicate if does not live in the same household.
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
Indicate if received additional therapy at school by Occupational therapist(OT), Speech therapist, Remedial teacher. Behavioural therapy by Psychologist.
Indicate if teachers were concerned
Include all assessments by therapists, school reports and please upload copies.
Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no for every question. Thank you very much.