Child's Name
*
First Name
Last Name
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
Additional information about type of class
Normal stream. Remedial. Or specialised class
Please indicate in months time you have been able to evaluate the behaviours:
*
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(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).
*
I accept
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Rating Scale.
A few teachers may feel some questions are not appropriate for high school children. These questions are international rating scales used by TEACHERS In North and South America, , Europe, Australasia and Africa. I you feel some questions do not apply to your learner then simply reply NEVER.
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
Instructions: Please describe what you see as this child's primary problems in each area and describe the effects of this child’s problems in that area over the past three months
*
Never
Occasional
Often
Very Often
1. How do this child's problems affect their relationship with other children?
2. How do this child's problems affect their relationship with the teacher
3. How do this child's problems affect their academic progress
4. How do this child's problems affect their self-esteem.
5. Overall severity of this child's problem in the overall need for treatment.
6. How your child's problems affect his or her relationship with playmates.
7. Regardless of whether this child is popular or unpopular with peers, does he or she have a special, close "best friend" that he or she has kept for more than a few months?
*
YES
NO
School work
*
Excellent
Above average
Average
Somewhat a Problem
Problematic
8.Reading
9.Mathematics
10. Written Expression
11. Relationship with peers
12. Following direction
13. Disrupting class
14. Assignment completion
15. Organisational skills
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Name of medication, dose of each tablet, total dose per day if you know
Medication
Dosage per tablet
Dosage school morning
Dosage school Lunchtime
Medications
Medications
Medications
Explain/Comments:
Additional comments
Inattention
Submit and wait for submission confirmation
Should be Empty: