Parent New Assessment FormsParent 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: email@example.comCompletion 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* 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 OtherPlease 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*yesNoDifficulty with excessive crying or sleeping problems.Problems During Birth* Birth at Term Birth Premature Normal APGAR score Abnormal APGAR Score Feeding Problems None OtherPlease 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 OtherMile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?Milestones Developmental*Immunizations Up-to-Date*YesNoPrevious or current medical or surgical problems* Tonsillectomy Adenoidectomy Grommet insertion Bone Fractures Lacerations and sutures (" Stitches") Asthma Allergies None OtherAny 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 OtherHas 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 noneOver sensitive to: labels on clothes, textures, sounds and busy environments, smells, heights or balance.Other Sensory Integration Problems*Hearing Test Performed*YesNoRecent? Audiologist or at school.Vision Test*YesNoRecent? Optometrist or at school? Wears spectacles?Sleeping Problems* Difficulty falling asleep Frequent waking Bedwetting Snores at night < 10 hours per night None OtherIn 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 OtherImpulsive eating leading to overeating.Other Eating Problems*Medications* Prescription Vitamins Difficulty swallowing tablets None OtherList 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 OtherCurrently or previously. Please indicate duration and name of therapistOther therapy received*Parental ConcernsBehavior Problems* Outbursts Defiant Oppositional Physical conflicts Home School None OtherInclude concerns experienced at school and outside of school frequently.Other behaviour problems*Bed-wetting or soiling* Bed-wetting Soiling No OtherOther Bed-wetting or soiling problems*Organisational Skills* Good Average Poor (Needs constant Supervision) Morning Routine Problematic Afternoon Routine Problematic Evening Routine Problematic OtherIndicate 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 OtherOther 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 IntactDivorcedHistory 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 OtherIndicate 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 OtherOther Family Medical History*SCHOOLING HISTORYTherapy at school or after-school* Remedial OT Speech therapy Psychological or Play therapy None Other or Current therapyIndicate 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 OtherIndicate if teachers were concernedOther Pre-School Problems*Junior School Problems* Concentration Behaviour and Emotional Task completion Learning None OtherIndicate if teachers were concernedOther Junior School Problems*High School Problems* Concentration Behaviour and Emotional Task completion Learning none OtherIndicate 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 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 OtherCurrently or previously.Other Therapist Assessment*Educational Assessment NON-VERBAL Result JSAIS ( IQ)* Not Completed Average Below average Above Average SuperiorIndicate from the Educational Psychological Assessment scoresEducational Assessment VERBAL Result JSAIS ( IQ)* Not Completed Average Below average Above Average SuperiorIndicate from the Educational Psychological Assessment scoresEducational Assessment GLOBAL Result JSAIS ( IQ)* Not Completed Average Below average Above Average SuperiorIndicate 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?1. Does not pay attention to details or makes careless mistakes with, for example, homework*NeverOccasionallyOftenVery Often2. Has difficulty keeping attention on what needs to be done*NeverOccasionallyOftenVery Often3. Does not seem to listen when spoken to directly*NeverOccasionallyOftenVery Often4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)*NeverOccasionallyOftenVery Often5. Has difficulty organizing tasks and activities*NeverOccasionallyOftenVery Often6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort*NeverOccasionallyOftenVery Often7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)*NeverOccasionallyOftenVery Often8. Is easily distracted by noises or other stimuli*NeverOccasionallyOftenVery Often9. Is forgetful in daily activities*NeverOccasionallyOftenVery Often10. Fidgets with hands or feet or squirms in seat*NeverOccasionallyOftenVery Often11. Leaves seat when remaining seated is expected*NeverOccasionallyOftenVery Often12. Runs about or climbs too much when remaining seated is expected*NeverOccasionallyOftenVery Often13. Has difficulty playing or beginning quiet play activities*NeverOccasionallyOftenVery Often14. Is “on the go” or often acts as if “driven by a motor”*NeverOccasionallyOftenVery Often15. Talks too much*NeverOccasionallyOftenVery Often16. Blurts out answers before questions have been completed*NeverOccasionallyOftenVery Often17. Has difficulty waiting his or her turn*NeverOccasionallyOftenVery Often18. Interrupts or intrudes on others’ conversations and/or activities*NeverOccasionallyOftenVery Often19. Argues with adults*NeverOccasionallyOftenVery Often20. Loses temper*NeverOccasionallyOftenVery Often21. Actively defies or refuses to go along with adults’ requests or rules*NeverOccasionallyOftenVery Often22. Deliberately annoys people*NeverOccasionallyOftenVery Often23. Blames others for his or her mistakes or misbehaviors*NeverOccasionallyOftenVery Often24. Is touchy or easily annoyed by others*NeverOccasionallyOftenVery Often25. Is angry or resentful*NeverOccasionallyOftenVery Often26. Is spiteful and wants to get even*NeverOccasionallyOftenVery Often27. Bullies, threatens, or intimidates others*NeverOccasionallyOftenVery Often28. Starts physical fights*NeverOccasionallyOftenVery Often29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)*NeverOccasionallyOftenVery Often30. Plays truant from school (skips school) without permission*NeverOccasionallyOftenVery Often31. Is physically cruel to people*NeverOccasionallyOftenVery Often32. Has stolen things that have value*NeverOccasionallyOftenVery Often33. Deliberately destroys others’ property*NeverOccasionallyOftenVery Often34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)*NeverOccasionallyOftenVery Often35. Is physically cruel to animals*NeverOccasionallyOftenVery Often36. Has deliberately set fires to cause damage*NeverOccasionallyOftenVery Often37. Has broken into someone else’s home, business, or car*NeverOccasionallyOftenVery Often38. Has stayed out at night without permission*NeverOccasionallyOftenVery Often39. Has run away from home overnight*NeverOccasionallyOftenVery Often40. Has forced someone into sexual activity*NeverOccasionallyOftenVery Often41. Is fearful, anxious, or worried*NeverOccasionallyOftenVery Often42. Is afraid to try new things for fear of making mistakes*NeverOccasionallyOftenVery Often43. Feels worthless or inferior*NeverOccasionallyOftenVery Often44. Blames self for problems, feels guilty*NeverOccasionallyOftenVery Often45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”*NeverOccasionallyOftenVery Often46. Is sad, unhappy, or depressed*NeverOccasionallyOftenVery Often47. Is self-conscious or easily embarrassed*NeverOccasionallyOftenVery Often48. Overall school performance*ExcellentAbove averageAverageSomewhat a ProblemProblematic49. Reading*ExcellentAbove averageAverageSomewhat a ProblemProblematic50. Writing*ExcellentAbove averageAverageSomewhat a ProblemProblematic51. Mathematics*ExcellentAbove averageAverageSomewhat a ProblemProblematic52. Relationship with parents*ExcellentAbove averageAverageSomewhat a ProblemProblematic53. Relationship with siblings*ExcellentAbove averageAverageSomewhat a ProblemProblematic54. Relationship with peers*ExcellentAbove averageAverageSomewhat a ProblemProblematic55. Participation in organized activities (eg, teams)*ExcellentAbove averageAverageSomewhat a ProblemProblematicSymptoms*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.NeverOccasionalOftenVery Often1.Fails to give attention to details or makes careless mistakes in schoolwork2. Has difficulty sustaining attention to tasks or activities3. 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 excessively16. Blurts out answers before questions have been completed17. Has difficulty waiting his or her turn (waiting in line)18. Interrupts or intrudes on others (eg, butts into conversations/games)19.Argues with adults20. Loses temper21.Actively defies or refuses to go along with adults’ requests or rules22. Deliberately annoys people23. Blames others for his or her mistakes or misbehaviors24. Is touchy or easily annoyed by others25.Is angry or resentful26.Is spiteful and wants to get even27. Bullies, threatens, or intimidates others28. Starts physical fights29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)30.Is truant from school (skips school) without permission31.Is physically cruel to people32. Has stolen things that have value33.Deliberately destroys others’ property34.Has used a weapon that can cause serious harm (bat, knife, brick, gun)35.Is physically cruel to animals36. Has deliberately set fires to cause damage37. Has broken into someone else’s home, business, or car38. Has stayed out at night without permission39. Has run away from home overnight40. Has forced someone into sexual activity41. Is fearful, anxious, or worried42. Is afraid to try new things for fear of making mistakes43. Feels worthless or inferior44. Blames self for problems, feels guilty45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”46. Is sad, unhappy, or depressed47. Is self-conscious or easily embarrassedAcademic performance*ExcellentAbove averageAverageSomewhat a ProblemProblematic48. Overall school performance49. Reading50. Writing51. Mathematics52. Relationship with parents53. Relationship with siblings54. Relationship with peers55. Participation in organized activities (eg, teams) This iframe contains the logic required to handle Ajax powered Gravity Forms.