Parent Follow-up Form

Parent Form for second and subsequent Doctor consultations

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.co.za

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • Please enter a number from 000 to 12.
  • Directions: Each rating should be considered in the context of what is appropriate for the age of your child. Please think about your child’s behaviors since the last assessment scale was filled out when rating his/her behaviors
    NeverOccasionalOftenVery OftenNot Applicable
    1. Does not pay attention to details or makes careless mistakes with, for example, homework
    2. Has difficulty keeping attention to what needs to be done
    3. Does not seem to listen when spoken to directly
    4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).
    5. Has difficulty organizing tasks and activities
    6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
    7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
    8. Is easily distracted by noises or other stimuli
    9. Is forgetful in daily activities
    10. Fidgets with hands or feet or squirms in seat
    11. Leaves seat when remaining seated is expected
    12. Runs about or climbs too much when remaining seated is expected
    13. Has difficulty playing or beginning quiet play activities
    14. Is “on the go” or often acts as if “driven by a motor”
    15. Talks too much
    16. Blurts out answers before questions have been completed
    17. Has difficulty waiting his or her turn (waiting in line)
    18. Interrupts or intrudes on others’ conversations and/or activities
  • ExcellentAbove averageAverageSomewhat a ProblemProblematic
    19. Overall school performance
    20. Reading
    21. Writing
    22. Mathematics
    23. Relationship with parents
    24. Relationship with siblings
    25. Relationship with peers
    26. Participation in organized activities (eg, teams)
    To maximise the treatment of your child, communication between all roll players involved in your child's management is vital.
  • Name of medication, dose of each tablet, total dose per day List all current medications here:
    MedicationDosage per tabletDosage MorningDosage schoolDosage AfternoonDosage daily Weekends 
  • 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)
  • 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)
  • 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)
  • Please tick any changes that have occurred since taking the current medication below
    Marked improvementSmall improvementNo changeSmall deteriorationMarked deteriorationNot applicable (medication not taken)
  • 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 allSometimesOftenAll 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)
  • Brief outline of questions to ask at appointment

3 thoughts on “Parent Follow-up Form”

  1. I will bring Dmirtiys School Report from last year to the Appointment.

    Mrs Peatt will be sending through her forms to you.

    Many thanks
    Natasha

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