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.

"*" indicates required fields

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

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user_id

Completion Date

Child's Name*

First Last

Gender*

Female

Male

Date of Birth of Child*

Mother*

First Last

Mother's place of employment*

Mother's type of employment*

e.g. accountant, engineer

Mother's age in years*

Mother's Education in years*

e.g. Matric level equivalent to 12 years.

Father*

First Last

Father's place of employment*

Father's type of employment*

e.g. accountant, engineer

Father's age in years*

Father's Education in years*

e.g. Matric level equivalent to 12 years.

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Cell Phone Parents*

Email Parent*

Enter Email Confirm Email

Name of School*

Name of Teacher*

First Last

Grade*

Please enter a number from 000 to 12.

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Cell Phone Teacher

Email of School or teacher*

Therapists seen(i.e. psychologist, OT, Speech etc) copy to

Name

First Last

Discipline

Psychologist, OT, Speech, GP etc

Name

First Last

Discipline

Psychologist, OT, Speech, GP etc

Name

First Last

Discipline

Psychologist, OT, Speech, GP etc

Name

First Last

Discipline

Psychologist, OT, Speech, GP etc

Additional therapists

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

First Name

Last Name

Discipline

Please include all professionals previously seen or currently seeing in the course of your child's assessment. Click the + to include another

Developmental and Medical History

Please include all information that you consider relevant. All information is confidential.

PREGNANCY AND DELIVERY

A. Length of pregnancy*

Length of pregnancy(e.g., full-term, 40 weeks, 32 weeks)

B. Length of delivery*

Length of delivery(number of hours from initial labour pains to birth)

C. Mother's age*

Mother's age when the child was born

D. Birth Weight*

Birth Weight(Kg)

E. Did any of the following conditions occur during pregnancy or delivery?

1. Bleeding*

Yes

2. Excessive weight gain (more than 13 kg)*

Yes

3. Toxaenia/preeclampsia*

Yes

4. Blood group incompatibility*

Yes

5. Frequent nausea and vomiting*

Yes

6. Serious illness or injury*

Yes

7. Took prescription medications. If yes, name of medication*

Yes

7a. Name of medication*

8. Took illegal drugs.*

Yes

9. Used alcoholic beverage. If yes approximately number of drinks per week.*

Yes

9a. Number of drinks per week

10. Smoked cigarettes. If yes, approximately number of cigarettes per day(e.g., 1/2 pack)*

Yes

10a. Approximately number of cigarettes per day(e.g., 1/2 pack)

11. Medication given to ease labour pains. If yes name of medicine.*

Yes

11a. Name of medication

12. Delivery was induced*

Yes

13. Forcepts were used during delivery*

Yes

14. Caesarean section*

Yes

15. Other problems, if yes please describe.*

Yes

Include severe stressors, e.g., death in the family, car accidents, relationship problems.

15a. Other problems

Include severe stressors, e.g., death in the family, car accidents, relationship problems.

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Problems during pregnancy*

Medications or substances taken

Stressor's

Complications

None

Other

Please include medical as well as psychological

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F. Did any of the following conditions affect your child during delivery or within the first few days after birth?

1. Injury during the delivery.*

Yes

2. Heart and lung distress during the delivery*

Yes

3. Delivered with cord around the neck.*

Yes

4. Had trouble breathing following delivery.*

Yes

5. Needed oxygen*

Yes

6. Cyanotic turned blue*

Yes

7. Was jaundiced, turned yellow.*

Yes

8. Had an infection.*

Yes

9. Had seizures.*

Yes

10. Was given medication.*

Yes

11. Born with a congenital defect.*

Yes

12. Was in hospital more than 7 days.*

Yes

INFANT HEALTH AND TEMPERAMENT

During the first 12 months, was your child:

1. Difficult to feed*

Yes

2. Difficult to get to sleep*

Yes

3. Colicky*

Yes

4. Difficult to put onto a schedule*

Yes

5. Alert*

Yes

6. Cheerful*

Yes

7. Affectionate*

Yes

8. Sociable*

Yes

9. Easy to comfort*

Yes

10. Difficult to keep busy*

Yes

11. Overactive, in constant motion*

Yes

12. Very stubborn, challenging*

Yes

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Colic or Cramps in the first 3 months*

yes

Other

Difficulty with excessive crying or sleeping problems.

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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.

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EARLY DEVELOPMENTAL MILESTONES

A. At what age did your child first accomplish the following

State in months and years, e.g., 6 months, 13 months or 1 year and one month.

1. Sitting without help*

2. Crawling*

3. Walking alone, without assistance*

4. Using single words(e.g., "mama," "dada," "ball")*

5. Putting two or more words together(e.g., "mama up")*

6. Bowel training, day and night.*

7. Bladder training day and night*

HEALTH HISTORY

At any time has your child had the following?

1. Asthma*

Never

Past

Present

2. Allergies*

Never

Past

Present

3. Diabetes, arthritis, or other chronic illnesses*

Never

Past

Present

4. Epilepsy or seizure disorder*

Never

Past

Present

5. Febrile seizures*

Never

Past

Present

6. Chickenpox or other common childhood illnesses*

Never

Past

Present

7. Heart or blood pressure problems*

Never

Past

Present

8. High fevers (> 39°c)*

Never

Past

Present

9. Broken bones*

Never

Past

Present

10. Severe cuts requiring stitches*

Never

Past

Present

11. Head injury with loss of consciousness*

Never

Past

Present

12. Lead poisoning.*

Never

Past

Present

13. Surgery*

Never

Past

Present

Other

Specify by selecting other

14. Lengthy hospitalisation Never Past Present*

Never

Past

Present

Other

Specify, select other

15. Speech or language problems*

Never

Past

Present

16. Chronic ear infections*

Never

Past

Present

17. Hearing difficulties*

Never

Past

Present

18. Eye or vision problems*

Never

Past

Present

19. Fine motor/handwriting problems*

Never

Past

Present

20. Gross motor difficulties, clumsiness*

Never

Past

Present

21. Appetite problems (overeating or under-eating)*

Never

Past

Present

22. Sleep problems (falling asleep, staying asleep)*

Never

Past

Present

23. Soiling problems Never Past Present*

Never

Past

Present

24. Wetting problems*

Never

Past

Present

25. Other health difficulties—please describe

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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?

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Milestones Developmental*

Immunizations Up-to-Date*

Yes

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Previous or current medical or surgical problems*

Any chronic illnesses, operations( tonsillectomy, adenoidectomy, grommets) , hospital admissions, broken bones or serious lacerations. Allergies to medications other other.

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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

Other

Is the child adopted?*

Yes

If yes, age when adopted

Age when adopted

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

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

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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, Max. file size: 1 GB.

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.*

My child currently does not take any medication for behaviour problems.

My answers are based on my child’s behaviour while OFF of medication.

My answers are based on my child’s behaviour while ON medication.

not sure?

Suppose your child is already taking medication for assistance with their behaviour management (such as Concerta) or any emotional difficulties (such as an antidepressant). In that case, we ask that you complete the questionnaires about your child’s behaviour based on how your child behaves when they are OFF this medication. Likely, you occasionally observe your child’s behaviour at periods when they are off of this medication, and we would be grateful if you could use those periods as the basis for answering these questions about behaviour. In this way, we can get a clearer idea of the true nature of your child’s difficulties without the alterations produced by any medication treatments. However, some parents whose children have been on medication for a long time may not be able to give us this information. In that case, complete the questionnaires based on your child’s behaviour, but check the question below to let us know that you based your judgments on your child’s behaviour when they were on medication. Check one of the boxes to let us know for sure on what basis you judged your child’s behaviour in answering our behaviour questionnaires:

I give consent to send a copy of the report to the teacher and therapists that you have seen.*

yes

Do you think your child may have ADHD?*

Yes

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

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

Home Situations Questionnaire

Instructions: Does this child present any problems with compliance to instructions, commands, or rules for you in any of the following situations? If so, please select next to the situation and rate how severe the problem is for you using the adjacent 1–9 scale, ranging from mild to severe if this child does not present a problem in a given situation, select No and go on to the next item on the form.

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Situations*

	Unsure	No	Yes	1	2	3	4	5	6	7	8	9
When arriving at school
During individual desk work
During free playtime in class
During class lessons
At recess
At lunch
In the hallways
In the bathroom
On school tips
During assemblies
School transport

Situations*

	Unsure	No	Yes	1	2	3	4	5	6	7	8	9
While playing alone
While playing with other children
At meal times
Getting dressed
Washing and bathing
While you are on the telephone
While watching TV
When visitors are in your home
When you are visiting someone's home
In public places(e.g., restaurants, shops)
When father is home
When asked to do chores
When asked to do homework
At bedtime
While in the car
When with an au pair or baby sitter

Number

I have read and accepted the terms of use, privacy policy, and sharing of personal information policy on the drflett.com website in terms of the South African POPI act. Including allowing the teacher(s) to complete the teacher's questionnaires that your have requested from the teacher(s).*

I accept