Parent New Assessment Form - Schooling Assessment

Parent Form for First 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.com
user_id
Completion Date
Date Format: DD slash MM slash YYYY
Child's Name*
First Last
Gender*
- Female
- Male
Date 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 Teacher
Grade*
Please enter a number from 000 to 12.
Email of School or teacher*

Therapists seen(i.e. psychologist etc) copy to

First Name	Last Name	Discipline	Email

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.
Problems during pregnancy*
- Medications or substances taken
- Stressor's
- Complications
- None
- Other
Please include medical as well as psychological
Other 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 vitamins

Other medications*

Medication	Dosage	Frequency

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 therapist
Other therapy received*
Behavior 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 HISTORY

Siblings' Names and Ages

Name	Age (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 completed
Other 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 HISTORY
Therapy 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 concerned
Other Pre-School Problems*
Junior School Problems*
- Concentration
- Behaviour and Emotional
- Task completion
- Learning
- None
- Other
Indicate if teachers were concerned
Other Junior School Problems*
High School Problems*
- Concentration
- Behaviour and Emotional
- Task completion
- Learning
- none
- Other
Indicate if teachers were concerned
Other High School Problems*
ASSESSMENTS COMPLETED
Include all assessments by therapists, school reports and please upload copies.
ASSESSMENTS COMPLETED and SCHOOL REPORTS
Drop files here or
Accepted file types: jpg, pdf, gif, png, doc, docx.
The more information received before the assessment ensures more time assessing your child during the consultation.
Therapist Assessment*
- Educational Assessment
- Occupational Therapist Assessment
- Remedial Teacher Assessment
- Speech Therapist Assessment
- Clinical or Counselling Psychologist Assessment
- Other
Currently or previously.
Other Therapist Assessment*
Educational Assessment NON-VERBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Educational Assessment VERBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Educational Assessment GLOBAL Result JSAIS ( IQ)*
- Not Completed
- Average
- Below average
- Above Average
- Superior
Indicate from the Educational Psychological Assessment scores
Additional information you wish to include
Is this evaluation based on a time when the child?*
- was on medication
- was not on medication
- not sure?
I give consent to send a copy of the report to the teacher and therapists that you have seen.*
- yes
- No
Do you think your child may have ADHD?*
- Yes
- No
- not sure?
What is your opinion on ADHD medications?*
Please indicate if you think medications can be effective for ADHD/concentration or are you against or not sure
- Yes
- No
- not sure?
1. Does not pay attention to details or makes careless mistakes with, for example, homework*
- Never
- Occasionally
- Often
- Very Often
2. Has difficulty keeping attention on what needs to be done*
- Never
- Occasionally
- Often
- Very Often
3. Does not seem to listen when spoken to directly*
- Never
- Occasionally
- Often
- Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)*
- Never
- Occasionally
- Often
- Very Often
5. Has difficulty organizing tasks and activities*
- Never
- Occasionally
- Often
- Very Often
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort*
- Never
- Occasionally
- Often
- Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)*
- Never
- Occasionally
- Often
- Very Often
8. Is easily distracted by noises or other stimuli*
- Never
- Occasionally
- Often
- Very Often
9. Is forgetful in daily activities*
- Never
- Occasionally
- Often
- Very Often
10. Fidgets with hands or feet or squirms in seat*
- Never
- Occasionally
- Often
- Very Often
11. Leaves seat when remaining seated is expected*
- Never
- Occasionally
- Often
- Very Often
12. Runs about or climbs too much when remaining seated is expected*
- Never
- Occasionally
- Often
- Very Often
13. Has difficulty playing or beginning quiet play activities*
- Never
- Occasionally
- Often
- Very Often
14. Is “on the go” or often acts as if “driven by a motor”*
- Never
- Occasionally
- Often
- Very Often
15. Talks too much*
- Never
- Occasionally
- Often
- Very Often
16. Blurts out answers before questions have been completed*
- Never
- Occasionally
- Often
- Very Often
17. Has difficulty waiting his or her turn*
- Never
- Occasionally
- Often
- Very Often
18. Interrupts or intrudes on others’ conversations and/or activities*
- Never
- Occasionally
- Often
- Very Often
19. Argues with adults*
- Never
- Occasionally
- Often
- Very Often
20. Loses temper*
- Never
- Occasionally
- Often
- Very Often
21. Actively defies or refuses to go along with adults’ requests or rules*
- Never
- Occasionally
- Often
- Very Often
22. Deliberately annoys people*
- Never
- Occasionally
- Often
- Very Often
23. Blames others for his or her mistakes or misbehaviors*
- Never
- Occasionally
- Often
- Very Often
24. Is touchy or easily annoyed by others*
- Never
- Occasionally
- Often
- Very Often
25. Is angry or resentful*
- Never
- Occasionally
- Often
- Very Often
26. Is spiteful and wants to get even*
- Never
- Occasionally
- Often
- Very Often
27. Bullies, threatens, or intimidates others*
- Never
- Occasionally
- Often
- Very Often
28. Starts physical fights*
- Never
- Occasionally
- Often
- Very Often
29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)*
- Never
- Occasionally
- Often
- Very Often
30. Plays truant from school (skips school) without permission*
- Never
- Occasionally
- Often
- Very Often
31. Is physically cruel to people*
- Never
- Occasionally
- Often
- Very Often
32. Has stolen things that have value*
- Never
- Occasionally
- Often
- Very Often
33. Deliberately destroys others’ property*
- Never
- Occasionally
- Often
- Very Often
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)*
- Never
- Occasionally
- Often
- Very Often
35. Is physically cruel to animals*
- Never
- Occasionally
- Often
- Very Often
36. Has deliberately set fires to cause damage*
- Never
- Occasionally
- Often
- Very Often
37. Has broken into someone else’s home, business, or car*
- Never
- Occasionally
- Often
- Very Often
38. Has stayed out at night without permission*
- Never
- Occasionally
- Often
- Very Often
39. Has run away from home overnight*
- Never
- Occasionally
- Often
- Very Often
40. Has forced someone into sexual activity*
- Never
- Occasionally
- Often
- Very Often
41. Is fearful, anxious, or worried*
- Never
- Occasionally
- Often
- Very Often
42. Is afraid to try new things for fear of making mistakes*
- Never
- Occasionally
- Often
- Very Often
43. Feels worthless or inferior*
- Never
- Occasionally
- Often
- Very Often
44. Blames self for problems, feels guilty*
- Never
- Occasionally
- Often
- Very Often
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”*
- Never
- Occasionally
- Often
- Very Often
46. Is sad, unhappy, or depressed*
- Never
- Occasionally
- Often
- Very Often
47. Is self-conscious or easily embarrassed*
- Never
- Occasionally
- Often
- Very Often
48. Overall school performance*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
49. Reading*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
50. Writing*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
51. Mathematics*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
52. Relationship with parents*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
53. Relationship with siblings*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
54. Relationship with peers*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic
55. Participation in organized activities (eg, teams)*
- Excellent
- Above average
- Average
- Somewhat a Problem
- Problematic

Symptoms*

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.

	Never	Occasional	Often	Very Often
1.Fails to give attention to details or makes careless mistakes in schoolwork
2. Has difficulty sustaining attention to tasks or activities
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 excessively
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 (eg, butts into conversations/games)
19.Argues with adults
20. Loses temper
21.Actively defies or refuses to go along with adults’ requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25.Is angry or resentful
26.Is spiteful and wants to get even
27. Bullies, threatens, or intimidates others
28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)
30.Is truant from school (skips school) without permission
31.Is physically cruel to people
32. Has stolen things that have value
33.Deliberately destroys others’ property
34.Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35.Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone else’s home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed

Academic performance*

	Excellent	Above average	Average	Somewhat a Problem	Problematic
48. Overall school performance
49. Reading
50. Writing
51. Mathematics
52. Relationship with parents
53. Relationship with siblings
54. Relationship with peers
55. Participation in organized activities (eg, teams)

Parent Form for First Doctor consultations

New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-768 8122 email: assessment@drjohnflett.com

Previous Medical History

FAMILY HISTORY

SCHOOLING HISTORY

ASSESSMENTS COMPLETED