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Menu
  • Home
  • Scripts
  • Forms
    • Parents
      • Parent New Assessment Form
      • Parent Follow-up Form
      • ADHD in GIRLS and WOMEN
      • Adult ADHD
      • MCHAT SCREEN for Autistic Spectrum Disorder
      • Video interview consent
    • Teachers
      • Teachers new patients
      • Teacher Follow-up Form

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.com

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Please enter a number from 000 to 12.
  • First NameLast NameDisciplineEmail 
    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
  • Please enter a number from 1 to 5.
    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
  • MedicationDosageFrequency 
    List all medications and other products. Click + other multiple items.
    Currently or previously. Please indicate duration and name of therapist
  • Parental Concerns

    Include concerns experienced at school and outside of school frequently.
    Indicate problems that occur daily or weekly requiring frequent attention.
  • FAMILY HISTORY

  • NameAge (years)Biological or step-sibling 
    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
  • SCHOOLING HISTORY

    Indicate if received additional therapy at school by Occupational therapist(OT), Speech therapist, Remedial teacher. Behavioural therapy by Psychologist.
    Indicate if teachers were concerned
  • ASSESSMENTS COMPLETED

    Include all assessments by therapists, school reports and please upload copies.
  • MCHAT

    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.
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