New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-768 8122 email: assessment@drjohnflett.com Child's Name*
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Gender* Mother*
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Father*
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Email Parent* Name of Teacher*
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Therapists seen(i.e. psychologist, OT, Speech etc) copy to Name
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Therapists seen(i.e. psychologist etc) copy to 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 Hidden
D. Birth Weight*
Birth Weight(Kg) eg 3.5kg
E. Did any of the following conditions occur during pregnancy or delivery? 1. Bleeding* 2. Excessive weight gain (more than 13 kg)* 3. Toxaenia/preeclampsia* 4. Blood group incompatibility* 5. Frequent nausea and vomiting* 6. Serious illness or injury* 7. Took prescription medications. If yes, name of medication* 8. Took illegal drugs.* 9. Used alcoholic beverage. If yes approximately number of drinks per week.* 10. Smoked cigarettes. If yes, approximately number of cigarettes per day(e.g., 1/2 pack)* 11. Medication given to ease labour pains. If yes name of medicine.* 12. Delivery was induced* 13. Forcepts were used during delivery* 14. Caesarean section* 15. Other problems, if yes please describe.* Include severe stressors, e.g., death in the family, car accidents, relationship problems.
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Problems during pregnancy* Please include medical as well as psychological
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.* 2. Heart and lung distress during the delivery* 3. Delivered with cord around the neck.* 4. Had trouble breathing following delivery.* 5. Needed oxygen* 6. Cyanotic turned blue* 7. Was jaundiced, turned yellow.* 8. Had an infection.* 9. Had seizures.* 10. Was given medication.* 11. Born with a congenital defect.* 12. Was in hospital more than 7 days.* INFANT HEALTH AND TEMPERAMENT During the first 12 months, was your child:
1. Difficult to feed* 2. Difficult to get to sleep* 3. Colicky* 4. Difficult to put onto a schedule* 5. Alert* 6. Cheerful* 7. Affectionate* 8. Sociable* 9. Easy to comfort* 10. Difficult to keep busy* 11. Overactive, in constant motion* 12. Very stubborn, challenging* Hidden
Colic or Cramps in the first 3 months* Difficulty with excessive crying or sleeping problems.
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Problems During Birth* Please indicate problems during, immediately after, and in the first month of life.
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.
HEALTH HISTORY At any time has your child had the following?
1. Asthma* 2. Allergies* 3. Diabetes, arthritis, or other chronic illnesses* 4. Epilepsy or seizure disorder* 5. Febrile seizures* 6. Chickenpox or other common childhood illnesses* 7. Heart or blood pressure problems* 8. High fevers (> 39°c)* 9. Broken bones* 10. Severe cuts requiring stitches* 11. Head injury with loss of consciousness* 12. Lead poisoning.* 13. Surgery* Specify by selecting other
14. Lengthy hospitalisation Never Past Present* Specify, select other
15. Speech or language problems* 16. Chronic ear infections* 17. Hearing difficulties* 18. Eye or vision problems* 19. Fine motor/handwriting problems* 20. Gross motor difficulties, clumsiness* 21. Appetite problems (overeating or under-eating)* 22. Sleep problems (falling asleep, staying asleep)* 23. Soiling problems Never Past Present* 24. Wetting problems* Hidden
Milestones and Development* Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?
Immunizations Up-to-Date* Hidden
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.
Speech and Language Difficulties* Has the teacher or other family members commented on speech or suggested speech therapy.
Gross and Fine Motor Problems* 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.
Sensory Integration Problems* Over sensitive to: labels on clothes, textures, sounds and busy environments, smells, heights or balance.
Hearing Test Performed* Recent? Audiologist or at school.
Vision Test* Recent? Optometrist or at school? Wears spectacles?
Sleeping Problems* In the Past or current? Nightmares or fearful at night? Strict sleeping routine? Restless? Excess TV or electronic devices.
Eating Problems* Impulsive eating leading to overeating.
Medications* List medications or vitamins
Other medications* List all medications and other products. Click + other multiple items.
Current or Previous Therapy received* Currently or previously. Please indicate duration and name of therapist
Behavior Problems* Include concerns experienced at school and outside of school frequently.
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Bed-wetting or soiling* Organisational Skills* Indicate problems that occur daily or weekly requiring frequent attention.
Emotional and Social Problems( at school and home)*
FAMILY HISTORY Siblings' Names and Ages Click +for more than one. Under 'Other' indicate if does not live in the same household.
Family Structure* Is the child adopted?* If yes, age when adopted
History of A.D.H.D or Learning Problems* 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
Family Medical History*
SCHOOLING HISTORY Therapy at school or after-school* Indicate if received additional therapy at school by Occupational therapist(OT), Speech therapist, Remedial teacher. Behavioural therapy by Psychologist.
Pre-School Problems* Indicate if teachers were concerned
Junior School Problems* Indicate if teachers were concerned
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High School Problems* Indicate if teachers were concerned
ASSESSMENTS COMPLETED Include all assessments by therapists, school reports and please upload copies.
ASSESSMENTS COMPLETED and SCHOOL REPORTS
The more information received before the assessment ensures more time assessing your child during the consultation.
Therapist Assessment* Currently or previously.
Educational Assessment NON-VERBAL Result JSAIS ( IQ)* Indicate from the Educational Psychological Assessment scores
Educational Assessment VERBAL Result JSAIS ( IQ)* Indicate from the Educational Psychological Assessment scores
Educational Assessment GLOBAL Result JSAIS ( IQ)* Indicate from the Educational Psychological Assessment scores
Additional information you wish to include
Is this evaluation based on.* 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.* Do you think your child may have ADHD?* 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
1. Does not pay attention to details or makes careless mistakes with, for example, homework* 2. Has difficulty keeping attention on what needs to be done* 3. Does not seem to listen when spoken to directly* 4. Does not follow through when given directions and fails to finish activities (not due to refusal 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* 18. Interrupts or intrudes on others’ conversations and/or activities* 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. Plays 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* 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)* 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.
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).*