Child's Name
*
First Name
Last Name
School Name
*
School currently attending.
School Email
*
example@example.com
Teacher's Name
*
First Name
Last Name
Parent's Email
*
Completing this field will notify the parents that you have kindly filled out the form. Please note that the contents of the form will remain confidential; only a notification of completion will be sent to the parents.
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.
10 Questions
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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
10 Evidence-Based Questions for a Teacher Follow-Up Consultation on ADHD Medication Effectiveness and School Performance.
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.
10 Questions.
*
No
Yes
Occasionally
NEVER
1.Attention and Focus: Have you noticed any changes in the child’s ability to pay attention and stay focused during lessons since starting the medication?
2. Classroom Behaviour: How has the child's behaviour in the classroom changed, if at all? Are they more or less disruptive than before?
3. Task Completion: Is the child completing tasks and assignments more consistently? Are they able to follow through on instructions better than before?
4. Academic Performance: Have you seen any improvements in the child’s academic performance, such as better grades or more accurate and timely homework submissions?
5. Interaction with Peers: How is the child interacting with their classmates? Have you noticed any changes in their social interactions, such as increased cooperation or reduced conflicts?
6. Emotional Regulation: Have there been any noticeable changes in the child’s emotional regulation? Are they managing frustration and anxiety better or worse?
7. Physical Side Effects: Have you observed any physical side effects that might be related to the medication, such as changes in appetite, weight, or sleep patterns?
8. Engagement and Participation: Is the child more engaged and participating more actively in class discussions and activities?
9. Independence and Initiative: Has there been any change in the child’s ability to work independently and take initiative in their learning?
10. Overall Feedback: Based on your observations, do you feel the current medication is effective in helping the child manage their ADHD symptoms?
School work
*
Excellent
Above average
Average
Somewhat a Problem
Problematic
11.Reading
12.Mathematics
13. Written Expression
14. Relationship with peers
15. Following direction
16. Disrupting class
17. Assignment completion
18. Organisational skills
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
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Are there specific areas where you think adjustments might be needed?
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: