Parent Follow-up FormParent 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: firstname.lastname@example.orgCompletion Date Date Format: DD slash MM slash YYYY Child's Name* First Last Gender*FemaleMaleDate of Birth of Child* Date Format: 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* Symptoms*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 behaviorsNeverOccasionalOftenVery OftenNot Applicable1. Does not pay attention to details or makes careless mistakes with, for example, homework2. Has difficulty keeping attention to what needs to be done3. Does not seem to listen when spoken to directly4. 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 activities6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)8. Is easily distracted by noises or other stimuli9. Is forgetful in daily activities10. Fidgets with hands or feet or squirms in seat11. Leaves seat when remaining seated is expected12. Runs about or climbs too much when remaining seated is expected13. Has difficulty playing or beginning quiet play activities14. Is “on the go” or often acts as if “driven by a motor”15. Talks too much16. Blurts out answers before questions have been completed17. Has difficulty waiting his or her turn (waiting in line)18. Interrupts or intrudes on others’ conversations and/or activitiesPerformance*ExcellentAbove averageAverageSomewhat a ProblemProblematic19. Overall school performance20. Reading21. Writing22. Mathematics23. Relationship with parents24. Relationship with siblings25. Relationship with peers26. Participation in organized activities (eg, teams)HYPERACTIVE/IMPULSIVECombined Inattentive &HYPERACTIVE/IMPULSIVEPERFORMANCE SCOREI give permission to Dr. Flett to send a medical report to the school and health care role player involved my child's management* Yes NoTo 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:MedicationDosage per tabletDosage MorningDosage schoolDosage AfternoonDosage daily Weekends ADHD Symptom Control*Please tick any changes that have occurred since taking the current medication belowMuch 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 belowMuch 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 belowMuch 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 belowMarked improvementSmall improvementNo changeSmall deteriorationMarked deteriorationNot 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 significantNot at allSometimesOftenAll the timeAppetite reductionWeight lossWeight gainStomach achesNauseaVomitingDiarrhoeaDryness (skin/ eyes/ mouth)ThirstSore throatSleep difficultiesTicsHeadacheMuscular tensionsFatigueDizzinessSweatingAgitation/excitabilityIrritabilityMood instabilityOver focus "zombie effect"SadnessHeart palpitationsFrequent urinationFeeling worse or different when the medication wears off (rebound)Items to discuss at the next medical appointment Brief outline of questions to ask at appointmentUpload Reports This iframe contains the logic required to handle Ajax powered Gravity Forms.