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
*
Yes
No
Is this evaluation based on a time when the child is on medication?
*
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 policy on the drflett.com website in terms of the South African POPI act. Please note information collected in this form will be automatically removed once clinically assessment has been completed to comply with drflett's information privacy policy.
*
I accept
Rating Scale
*
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
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
RATE the medication
*
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
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
Does NOT satisfy criteria for Inattentive type ADHD
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