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    • Teachers
      • Teachers new patients
      • Teacher Follow-up Form
  • Home
  • Scripts
  • Forms
    • Parents
      • Parent New Assessment Form
      • Parent Follow-up Form
      • ADHD in GIRLS and WOMEN
      • Adult ADHD
      • MCHAT SCREEN for Autistic Spectrum Disorder
      • Video interview consent
    • Teachers
      • Teachers new patients
      • Teacher Follow-up Form
General Instructions for Preparing for your child’s Evaluation

"*" indicates required fields

Step 1 of 10 - Contact Details

10%

New Assessment Form Dr. John Flett. The Assessment Center, 8 Village Road Kloof www. drflett.com, 031-1000 474 email: assessment@drjohnflett.com

This field is hidden when viewing the form
DD slash MM slash YYYY
Child's Name*
Gender*
DD slash MM slash YYYY
Mother*
e.g. accountant, engineer
e.g., Matric level equivalent to 12 years. Insert 12 NOT 12 y or 12 years. Insert number only
Father*
e.g. accountant, engineer
e.g., Matric level equivalent to 12 years. Insert 12, NOT 12 y or 12 years. Insert number only
This field is hidden when viewing the form
Email Parent*
Name of Teacher*
Please enter a number from 000 to 15.
If a child is under 6y, enter 0. If at College, university or out of school enter 13.
This field is hidden when viewing the form

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

Name
Psychologist, OT, Speech, GP etc
Name
Psychologist, OT, Speech, GP etc
Name
Psychologist, OT, Speech, GP etc
Name
Psychologist, OT, Speech, GP etc
This field is hidden when viewing the form
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

Developmental and Medical History

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

PREGNANCY AND DELIVERY

Length of pregnancy(e.g., full-term, 40 weeks, 32 weeks)
Length of delivery(number of hours from initial labour pains to birth)
Mother's age when the child was born
This field is hidden when viewing the form
Birth Weight(Kg) eg 3.5kg
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.
Include severe stressors, e.g., death in the family, car accidents, relationship problems.
This field is hidden when viewing the form
Problems during pregnancy*
Please include medical as well as psychological
This field is hidden when viewing the form

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*
This field is hidden when viewing the form
Colic or Cramps in the first 3 months*

Difficulty with excessive crying or sleeping problems.
This field is hidden when viewing the form
Problems During Birth*
Please indicate problems during, immediately after, and in the first month of life.
This field is hidden when viewing the form

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*

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*
This field is hidden when viewing the form
Milestones and Development*
Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?
This field is hidden when viewing the form
Immunizations Up-to-Date*
This field is hidden when viewing the form
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.
This field is hidden when viewing the form
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*
Medication
Dosage
Frequency
 
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.
This field is hidden when viewing the form
Bed-wetting or soiling*
This field is hidden when viewing the form
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
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*

Are both parents the biological parents?*
If No, indicate if conceived by IVF
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*
PARENT CHARACTERISTICS*
Any problems of your own that you believe may contribute to difficulties you have in managing your child or children

Parent experience at school

Your responses to these questions will be valuable in providing a comprehensive understanding of the familial and environmental factors that could be influencing your child's development and progress. Your responses will be kept confidential and used solely for this purpose. Please answer all questions as accurately as possible.
1. Did either parent experience the following social challenges at school? (Select all that apply)*
Indicate whether either parent had challenges at school.
2. Which of the following academic challenges did either parent experience during their schooling? (Select all that apply)*
Indicate whether either parent had challenges at school.
3. During their schooling, did either parent experience the following? (Select all that apply)*
Indicate whether either parent had challenges at school.
4. Which of the following describes either parent's work habits during their schooling? (Select all that apply)*
Indicate whether either parent had challenges at school.
5. Did either parent require additional academic support during their school years in any of the following ways? (Select all that apply)*
Indicate whether either parent had challenges at school.
6. After school, which of the following paths did either parent follow? (Select all that apply)*
Indicate whether either parent had challenges at school.
7. Would you describe either parent's school experience as being more focused on the following aspects rather than the academics? (Select all that apply)*
Indicate whether either parent had challenges at school.
8. Did either parent receive treatment for any of the following during or after their school years? (Select all that apply)*
Indicate whether either parent had challenges at school.
9. Did either parent use any of the following illicit substances during their school years? (Select all that apply)*
Indicate whether either parent had challenges at school.

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
This field is hidden when viewing the form
Junior School Problems*
Indicate if teachers were concerned
This field is hidden when viewing the form
This field is hidden when viewing the form
High School Problems*
Indicate if teachers were concerned

ASSESSMENTS COMPLETED

Include all assessments by therapists, school reports and please upload copies.
Drop files here or
Accepted file types: jpg, pdf, gif, png, doc, docx, Max. file size: 100 MB, Max. files: 4.
    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 ONLY from the Educational Psychological Assessment scores
    Educational Assessment VERBAL Result JSAIS ( IQ)*
    Indicate ONLY from the Educational Psychological Assessment scores
    Educational Assessment GLOBAL Result JSAIS ( IQ)*
    Indicate ONLY from the Educational Psychological Assessment scores
    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.
    This field is hidden when viewing the form
    UnsureNoYes123456789
    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
    UnsureNoYes123456789
    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
    This field is hidden when viewing the form
    This field is hidden when viewing the form
    Over 6 significant
    This field is hidden when viewing the form
    Over 6 significant
    This field is hidden when viewing the form
    Referral Source*
    How did you hear about Dr Flett?
    I have read and accepted the terms of use, privacy policy, and sharing of personal information(including email addresses) policy on the drflett.com website in terms of the South African POPI Act. Please note the information collected in this form maybe be automatically removed once the clinical assessment has been completed to comply with drflett's information privacy policy (Please refer to the Privacy Statement at the bottom menu of drflett.com).Including allowing the teacher(s) to complete the teacher's questionnaires that you have requested from the teacher(s).*
    This field is for validation purposes and should be left unchanged.

    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

    Step 1 of 10 - Contact Details

    10%

    New Assessment Form Dr. John Flett. The Assessment Center, 8 Village Road Kloof www. drflett.com, 031-1000 474 email: assessment@drjohnflett.com

    This field is hidden when viewing the form
    DD slash MM slash YYYY
    Child's Name*
    Gender*
    DD slash MM slash YYYY
    Mother*
    e.g. accountant, engineer
    e.g., Matric level equivalent to 12 years. Insert 12 NOT 12 y or 12 years. Insert number only
    Father*
    e.g. accountant, engineer
    e.g., Matric level equivalent to 12 years. Insert 12, NOT 12 y or 12 years. Insert number only
    This field is hidden when viewing the form
    Email Parent*
    Name of Teacher*
    Please enter a number from 000 to 15.
    If a child is under 6y, enter 0. If at College, university or out of school enter 13.
    This field is hidden when viewing the form

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

    Name
    Psychologist, OT, Speech, GP etc
    Name
    Psychologist, OT, Speech, GP etc
    Name
    Psychologist, OT, Speech, GP etc
    Name
    Psychologist, OT, Speech, GP etc
    This field is hidden when viewing the form
    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

    Developmental and Medical History

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

    PREGNANCY AND DELIVERY

    Length of pregnancy(e.g., full-term, 40 weeks, 32 weeks)
    Length of delivery(number of hours from initial labour pains to birth)
    Mother's age when the child was born
    This field is hidden when viewing the form
    Birth Weight(Kg) eg 3.5kg
    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.
    Include severe stressors, e.g., death in the family, car accidents, relationship problems.
    This field is hidden when viewing the form
    Problems during pregnancy*
    Please include medical as well as psychological
    This field is hidden when viewing the form

    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*
    This field is hidden when viewing the form
    Colic or Cramps in the first 3 months*

    Difficulty with excessive crying or sleeping problems.
    This field is hidden when viewing the form
    Problems During Birth*
    Please indicate problems during, immediately after, and in the first month of life.
    This field is hidden when viewing the form

    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*

    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*
    This field is hidden when viewing the form
    Milestones and Development*
    Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?
    This field is hidden when viewing the form
    Immunizations Up-to-Date*
    This field is hidden when viewing the form
    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.
    This field is hidden when viewing the form
    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*
    Medication
    Dosage
    Frequency
     
    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.
    This field is hidden when viewing the form
    Bed-wetting or soiling*
    This field is hidden when viewing the form
    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
    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*

    Are both parents the biological parents?*
    If No, indicate if conceived by IVF
    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*
    PARENT CHARACTERISTICS*
    Any problems of your own that you believe may contribute to difficulties you have in managing your child or children

    Parent experience at school

    Your responses to these questions will be valuable in providing a comprehensive understanding of the familial and environmental factors that could be influencing your child's development and progress. Your responses will be kept confidential and used solely for this purpose. Please answer all questions as accurately as possible.
    1. Did either parent experience the following social challenges at school? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    2. Which of the following academic challenges did either parent experience during their schooling? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    3. During their schooling, did either parent experience the following? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    4. Which of the following describes either parent's work habits during their schooling? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    5. Did either parent require additional academic support during their school years in any of the following ways? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    6. After school, which of the following paths did either parent follow? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    7. Would you describe either parent's school experience as being more focused on the following aspects rather than the academics? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    8. Did either parent receive treatment for any of the following during or after their school years? (Select all that apply)*
    Indicate whether either parent had challenges at school.
    9. Did either parent use any of the following illicit substances during their school years? (Select all that apply)*
    Indicate whether either parent had challenges at school.

    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
    This field is hidden when viewing the form
    Junior School Problems*
    Indicate if teachers were concerned
    This field is hidden when viewing the form
    This field is hidden when viewing the form
    High School Problems*
    Indicate if teachers were concerned

    ASSESSMENTS COMPLETED

    Include all assessments by therapists, school reports and please upload copies.
    Drop files here or
    Accepted file types: jpg, pdf, gif, png, doc, docx, Max. file size: 100 MB, Max. files: 4.
      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 ONLY from the Educational Psychological Assessment scores
      Educational Assessment VERBAL Result JSAIS ( IQ)*
      Indicate ONLY from the Educational Psychological Assessment scores
      Educational Assessment GLOBAL Result JSAIS ( IQ)*
      Indicate ONLY from the Educational Psychological Assessment scores
      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.
      This field is hidden when viewing the form
      UnsureNoYes123456789
      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
      UnsureNoYes123456789
      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
      This field is hidden when viewing the form
      This field is hidden when viewing the form
      Over 6 significant
      This field is hidden when viewing the form
      Over 6 significant
      This field is hidden when viewing the form
      Referral Source*
      How did you hear about Dr Flett?
      I have read and accepted the terms of use, privacy policy, and sharing of personal information(including email addresses) policy on the drflett.com website in terms of the South African POPI Act. Please note the information collected in this form maybe be automatically removed once the clinical assessment has been completed to comply with drflett's information privacy policy (Please refer to the Privacy Statement at the bottom menu of drflett.com).Including allowing the teacher(s) to complete the teacher's questionnaires that you have requested from the teacher(s).*
      This field is for validation purposes and should be left unchanged.
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