Child's Name
*
First Name
Last Name
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Parent's Email
*
example@example.com
School Name
*
School currently attending.
School Email
example@example.com
Teacher's Name
*
First Name
Last Name
Teacher's Email
*
example@example.com
Grade
*
Today's Date
-
Day
-
Month
Year
Date
I give permission to Dr. Flett to send a medical report to the school and health care role player involved my child's management
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Yes
No
Is this evaluation based on a time when the child is on medication?
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was on medication
was not on medication
not sure
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 information collected in this form maybe be automatically removed once clinically 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).
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I accept
Rating Scale
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Never
Occasional
Often
Very Often
1.Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. 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 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 (waiting in line)
18. Interrupts or intrudes on others’ conversations and/or activities
Over the last 4 weeks has your child had these problems ..
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Never
Occasional
Often
Very Often
N/A (not relevant / not observed)
1 Having problems with brothers & sisters
2 Causing problems between parents
3 Takes time away from family members’ work or activities
4 Causing fighting in the family
5 Isolating the family from friends and social activities
6 It Makes it hard for the family to have fun together
7 Makes parenting difficult
8 Makes it hard to give fair attention to all family members
9 Provokes others to hit or scream at him/her
10 Costs the family more money
1 It Makes it difficult to keep up with schoolwork
2 Needs extra help at school
3 Needs tutoring
4 Receives grades that are not as good as his/her ability
1 Causes problems for the teacher in the classroom
2 Receives “time-out” or removal from the classroom
3 Having problems in the schoolyard
4 Receives detentions (during or after school)
5 Suspended or expelled from school
6 Misses classes or is late for school
1 Excessive use of TV, computer, or video games
2 Keeping clean, brushing teeth, brushing hair, bathing, etc.
3 Problems getting ready for school
4 Problems getting ready for bed
5 Problems with eating (picky eater, junk food)
6 Problems with sleeping
7 Gets hurt or injured
8 Avoids exercise
9 Needs more medical care
1. Being teased or bullied by other children
2 Teases or bullies other children
3 Problems getting along with other children
4 Problems participating in after-school activities (sports, music,
clubs)
5 Problems making new friends
6 Problems keeping friends
7 Difficulty with parties (not invited, avoids them, misbehaves)
1 Easily led by other children (peer pressure)
2 Breaking or damaging things
3 Doing illegal things
4Taking illegal drugs
5 Doing dangerous things
6 Causes injury to others
7 Says mean or inappropriate things
Compared with the last review, overall things are:
*
Much worse
Worse
No change
Better
Much better
The Daily Pressure Points
Type a question
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Never
Occasionally
Often
Very often
N/A (not relevant / not observed)
1. Getting out of bed / starting the day
2. Getting dressed / hygiene without battles
3. Breakfast / eating enough in the morning
4. Leaving the house on time
5. After-school crash (meltdowns/irritability/tiredness)
6. Starting homework (initiation)
7. Finishing homework (completion)
8. Written work (handwriting/typing/paragraphs) is a bottleneck
9. Packing bag / remembering books/diary/permission slips
10. Screen use causes conflict or delays responsibilities
11. Bedtime routine (winding down without conflict)
12. Falling asleep / staying asleep
13. Grades/results are below abilit
Emotions & Behaviour
Emotions & Behaviour
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Never
Occasionally
Often
Very often
N/A (not relevant / not observed)
1. Big emotions over small triggers (fast escalation)
2. Shuts down / refuses when tasks feel hard
3. Argues / negotiates / pushes back on instructions
4. Angry outbursts (shouting, slamming doors)
5. Tearful / easily hurt / “everything feels too much”
6. Anxiety worries (school, mistakes, performance, social)
7. Low confidence / says “I’m dumb/I can’t”
8. Tantrums/meltdowns when screens are removed
9. Impulsive behaviour (interrupts, blurts, does before thinking)
10. Risky behaviour for age (for younger kids mark N/A)
Social & Friends
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Never
Occasionally
Often
Very often
N/A (not relevant / not observed)
1. Struggles to make friends
2. Struggles to keep friends (falls out often)
3. Gets into conflict with peers (teasing, arguments, aggression)
4. Feels left out / not invited / avoids parties
5. Peer pressure / easily led (upper primary + teens; N/A for younger)
6. After-school activities are hard (sport, clubs, homework overload, behaviour)
Health & Lifestyle
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Never
Occasionally
Often
Very often
N/A (not relevant / not observed)
1. Picky eating / food battles
2. Craves junk food / snacks constantly
3. Not eating enough (or appetite very low)
4. Too much screen time overall
5. Not enough movement/exercise
6. Headaches / tummy aches linked to school stress
7. Gets hurt often / accidents more than peers
8. Sleep routine is inconsistent (bedtime shifts, late nights)
Family impact
*
Never
Occasionally
Often
Very often
N/A (not relevant / not observed)
1. Parenting feels exhausting/overwhelming
2. Siblings conflict is frequent
3. Couple/parent conflict is increased
4. Family avoids outings/social events
5. Family routines feel chaotic
6. Financial strain because of extra support (tutoring/therapy/childcare)
Medications
1. Is your child taking ADHD medication currently?
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Yes
No
If yes: Is it taken on school days?
*
Always
Sometimes
Often
No sure
RATE the medication
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1
2
3
4
5
6
7
8
9
10
Nasty experience with no benefits and lots of side effects
The best result you can image without side-effects
1 is Nasty experience with no benefits and lots of side effects, 10 is The best result you can image without side-effects
Homework time is outside medication coverage.
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Never
Sometimes
Often
No sure
Most common side effects in the last 2 weeks
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• Appetite down
• Trouble falling asleep
• Irritable / short fuse (especially late afternoon)
• Flat / “too quiet”
• Headache / tummy ache
• Tics (new or worse)
• None / Not sure
Teens
Late-night phone use is affecting sleep
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Never
Sometimes
Often
Homework is done very late (after 8pm)
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Never
Sometimes
Often
Risk behaviours
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• Vaping/nicotine
• Alcohol
• Cannabis/other substances
• Sneaking out/unsafe situations
• Online risk (sexting/scams)
• None / Prefer not to say
Over the last 4 weeks have you been worried that the medication is causing problems with clear thinking("zoning out"/staring,Thoughts foggy or spacey),Motivation(Loss of intrinsic motivation,Less motivated to achieve goals) and mood(Dampening of mood/spontaneity,"Feel like I'd lost spark")?
No, not at all
Yes, I think so
I'm not sure
Over the last 4 weeks has your child had these problems ....
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Not at all
A little
A lot
Completely
Yes, Is this a problem for you?
No, this isn't a problem for you.
1.Over-focused on jobs you had to do
2. Had trouble remembering recent experiences or events
3. Had trouble thinking of different ways to do things (e.g., like when you are doing a maths problem)
4. Felt like you weren't putting much effort into things
5. Been anxious or worried
6. Not been interested or excited to achieve your goals
7. Been distracted
8. Expected or wanted other people to praise or reward you
9. Been emotional (e.g., had lots of strong feelings)
10. Fidgets with hands or feet or squirms in seat
11. Felt more boring and less exciting than usual
12. Been thinking slowly
13. Been well behaved
14. Noticed your thinking was fuzzy or confused
15. Felt nervous or had butterflies in your stomach
16. Not been creative
17. Noticed your mood or temper kept changing
18. Been sensitive to sights, sounds, or touch
19. Been focused on doing things in a certain way
20. Been forgetful
21. Not been pushing yourself to work as hard or harder than other people
22. Needed and wanted to be rewarded for work/behaviour
23. Been focused on your own thoughts (e.g., can't get out of your head)
24. Not shown creativity
25. Had trouble trying to understand other people's views or opinions
26. Had slow reflexes or reacted slowly
27. Found it difficult to think quickly
28. Found it really hard to start your normal everyday tasks (e.g., morning work or household chores)
29. Been “good”
30. Thought too hard or were lost in your own thoughts
31. Stared at things or people
Name of medication, dose of each tablet, total dose per day
Medication
Dosage per tablet
Dosage school morning
Dosage school Lunchtime
Medications
Medications
Medications
Explain/Comments:
Additional comments
Performance
Excellent
Above average
Average
Somewhat a Problem
Problematic
19.Reading
20. Mathematics
21. Written Expression
22. Relationship with parents
23. Relationship with siblings
24. Relationship with peers
25. Participation in organized activities (eg, teams)
26. Overall school performance
ADHD Symptom Control
*
-3
-2
-1
0
1
2
3
Much Worst
Much better
-3 is Much Worst, 3 is Much better
Please tick the frequency of any side effects experienced with the current treatment since your last medical appointment. Contact me if side effects are significant
Not at all
Sometimes
Often
All the time
Appetite reduction
Weight loss
Stomach aches
Nausea
Sleep difficulties
Tics
Headache
Dizziness
Sweating
Agitation/excitability
Irritability
Mood instability
Over focus "zombie effect"
Heart palpitations
Feeling worse or different when the medication wears off (rebound)
Items to discuss at the next medical appointment
Brief outline of questions to ask at appointment
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Satisfies criteria for Inattentive type ADHD
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