Parent New Assessment Form 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.comHiddenuser_id Completion Date DD slash MM slash YYYY Child's Name* First Last Gender* Female Male Date of Birth of Child* 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* Therapists seen(i.e. psychologist etc) copy toFirst NameLast NameDisciplineEmail Please include all professionals previously seen or currently seeing in the course of your child's assessment. Click the + to include anotherPrevious Medical HistoryPlease 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 psychologicalOther 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 vitaminsOther medications*MedicationDosageFrequency 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 therapistOther 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 HISTORYSiblings' Names and AgesNameAge (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 completedOther 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 HISTORYTherapy 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 concernedOther Pre-School Problems* Junior School Problems* Concentration Behaviour and Emotional Task completion Learning None Other Indicate if teachers were concernedOther Junior School Problems* High School Problems* Concentration Behaviour and Emotional Task completion Learning none Other Indicate if teachers were concernedOther High School Problems* ASSESSMENTS COMPLETEDInclude all assessments by therapists, school reports and please upload copies.ASSESSMENTS COMPLETED and SCHOOL REPORTS Drop files here or Select files Accepted file types: jpg, pdf, gif, png, doc, docx, Max. file size: 256 MB. 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 scoresEducational Assessment VERBAL Result JSAIS ( IQ)* Not Completed Average Below average Above Average Superior Indicate from the Educational Psychological Assessment scoresEducational Assessment GLOBAL Result JSAIS ( IQ)* Not Completed Average Below average Above Average Superior Indicate from the Educational Psychological Assessment scoresAdditional information you wish to includeIs 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 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.* I accept HiddenSymptoms*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.HiddenAcademic performance*
