MCHAT SCREEN for Autistic Spectrum Disorder MCHAT screen for ASD 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. New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-768 8122 email: assessment@drjohnflett.comCompletion Date DD slash MM slash YYYY Child's Name* First Last Gender* Female Male Date of Birth of Child* DD slash MM slash YYYY Mother* First Last Father* First Last Cell Phone Parents*Email Parent* Enter Email Confirm Email Name of School* Name of Teacher* First Last Cell Phone TeacherGrade*Please enter a number from 000 to 12.Email of School or teacher* Therapists seen(i.e. psychologist etc) copy toFirst NameLast NameDisciplineEmail Please include all professionals previously seen or currently seeing in the course of your child's assessment. Click the + to include anotherPrevious Medical HistoryPlease 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 psychologicalOther 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 Difficulty swallowing tablets None Other List medications or vitaminsOther medications*MedicationDosageFrequency 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 therapistOther therapy received* Parental ConcernsBehavior 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 HISTORYSiblings' Names and AgesNameAge (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 completedOther 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 HISTORYTherapy 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 concernedOther Pre-School Problems* ASSESSMENTS COMPLETEDInclude all assessments by therapists, school reports and please upload copies.Additional information you wish to includeMCHATPlease 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.1. If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)* Yes No 2.Have you ever wondered if your child might be deaf?* Yes No 3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)* Yes No 4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)* Yes No 5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)* Yes No 6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)* Yes No 7.Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)* Yes No 8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)* Yes No 9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)* Yes No 10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)* Yes No 11. When you smile at your child, does he or she smile back at you?* Yes No 12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)* Yes No 13. Does your child walk?* Yes No 14. Does your child look you in the eye when you are talking to him or her, playing with him Yes No or her, or dressing him or her?* Yes No 15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)* Yes No 16. If you turn your head to look at something, does your child look around to see what you are looking at?* Yes No 17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)* Yes No 18. IDoes your child understand when you tell him or her to do something? (FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”?)* Yes No 19. If something new happens, does your child look at your face to see how you feel about it? (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)* Yes No 20.Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)* Yes No
