MCHAT screen for ASD

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.

• New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-768 8122 email: assessment@drjohnflett.com

• Completion Date
  
  Date Format: DD slash MM slash YYYY
  
• Child’s Name*
  
  First
  
  Last
• Gender*
  • Female
  • Male
• Date of Birth of Child*
  
  Date Format: DD slash MM slash YYYY
  
• Mother*
  
  First
  
  Last
• Father*
  
  First
  
  Last
• Cell Phone Parents*
• Email Parent*
  
  Enter Email
  
  Confirm Email
• Name of School*
• Name of Teacher*
  
  First
  
  Last
• Cell Phone Teacher
• Grade*Please enter a number from 000 to 12.
• Email of School or teacher*
  
• 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

• Previous Medical History

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

• Problems during pregnancy*
  • 
    Medications or substances taken
  • 
    Stressor’s
  • 
    Complications
  • 
    None
  • 
    Other

  Please include medical as well as psychological

• Other Problems during pregnancy*
• Birth Weight(Kg)*Please enter a number from 1 to 5.
• Colic or Cramps in the first 3 months*
  • yes
  • No

  Difficulty with excessive crying or sleeping problems.

• Problems During Birth*
  • 
    Birth at Term
  • 
    Birth Premature
  • 
    Normal APGAR score
  • 
    Abnormal APGAR Score
  • 
    Feeding Problems
  • 
    None
  • 
    Other

  Please indicate problems during, immediately after, and in the first month of life.

• Other Problems During Birth*
• Milestones and Development*
  • 
    All age appropriate
  • 
    Sitting/crawling/ Walking /Delayed
  • 
    Abnormal Speech or delay
  • 
    Other

  Mile stones such as sitting, crawling, walking achieved normally or delayed? Specifically was there speech delay?

• Milestones Developmental*
• Immunizations Up-to-Date*
  • Yes
  • No
• Previous or current medical or surgical problems*
  • 
    Tonsillectomy
  • 
    Adenoidectomy
  • 
    Grommet insertion
  • 
    Bone Fractures
  • 
    Lacerations and sutures (” Stitches”)
  • 
    Asthma
  • 
    Allergies
  • 
    None
  • 
    Other

  Any chronic illnesses, operations( tonsillectomy, adenoidectomy, grommets) , hospital admissions, broken bones or serious lacerations. Allergies to medications other other.

• Other medical or surgical problems*
• Speech and Language Difficulties*
  • 
    Articulation( pronunciation)
  • 
    Lisp
  • 
    Stutter
  • 
    Phonics
  • 
    None
  • 
    Other

  Has the teacher or other family members commented on speech or suggested speech therapy.

• Other Speech and Language Difficulties*
• Gross and Fine Motor Problems*
  • 
    Pencil Grip
  • 
    Colouring and Cutting
  • 
    Clumsy
  • 
    Posture
  • 
    None
  • 
    other

  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.

• Other Gross and Fine Motor Problems*
• Sensory Integration Problems*
  • 
    Tactile (touch)
  • 
    Auditory (sound)
  • 
    Vestibular (balance)
  • 
    Olfactory (smell)
  • 
    Other
  • 
    none

  Over sensitive to: labels on clothes, textures, sounds and busy environments, smells, heights or balance.

• Other Sensory Integration Problems*
• Hearing Test Performed*
  • Yes
  • No

  Recent? Audiologist or at school.

• Vision Test*
  • Yes
  • No

  Recent? Optometrist or at school? Wears spectacles?

• Sleeping Problems*
  • 
    Difficulty falling asleep
  • 
    Frequent waking
  • 
    Bedwetting
  • 
    Snores at night
  • 
    < 10 hours per night
  • 
    None
  • 
    Other

  In the Past or current? Nightmares or fearful at night? Strict sleeping routine? Restless? Excess TV or electronic devices.

• Other sleeping Problems*
• Eating Problems*
  • 
    Fussy
  • 
    Overeating
  • 
    Overweight
  • 
    No
  • 
    Other

  Impulsive eating leading to overeating.

• Other Eating Problems*
• Medications*
  • 
    Prescription
  • 
    Vitamins
  • 
    Difficulty swallowing tablets
  • 
    None
  • 
    Other

  List medications or vitamins

• Other medications*
  

  Medication	Dosage	Frequency

  List all medications and other products. Click + other multiple items.

• Current or Previous Therapy received*
  • 
    Occupational
  • 
    Speech
  • 
    Remedial
  • 
    Psychological
  • 
    Homeopathic
  • 
    Neurofeedback
  • 
    Behavior Optometry
  • 
    None
  • 
    Other

  Currently or previously. Please indicate duration and name of therapist

• Other therapy received*

• Parental Concerns

• Behavior Problems*
  • 
    Outbursts
  • 
    Defiant
  • 
    Oppositional
  • 
    Physical conflicts
  • 
    Home
  • 
    School
  • 
    None
  • 
    Other

  Include concerns experienced at school and outside of school frequently.

• Other behaviour problems*
• Bed-wetting or soiling*
  • 
    Bed-wetting
  • 
    Soiling
  • 
    No
  • 
    Other
• Other Bed-wetting or soiling problems*
• Organisational Skills*
  • 
    Good
  • 
    Average
  • 
    Poor (Needs constant Supervision)
  • 
    Morning Routine Problematic
  • 
    Afternoon Routine Problematic
  • 
    Evening Routine Problematic
  • 
    Other

  Indicate problems that occur daily or weekly requiring frequent attention.

• Other Organisational problems*
• Emotional and Social Problems( at school and home)*
  • 
    Many friends ( Gregarious) sustains friendships
  • 
    Few Friends. Cannot sustain friendships.
  • 
    Mood has significant daily impact at home
  • 
    Mood has significant daily impact at school
  • 
    Socially withdrawn.
  • 
    Problems with Siblings
  • 
    None
  • 
    Other
• Other Emotional and Social Problems*

• 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*
  • Family Intact
  • Divorced
• History of A.D.H.D or Learning Problems*
  • 
    Father with ADHD
  • 
    Mother with ADHD
  • 
    Sibling with ADHD
  • 
    Relative with ADHD
  • 
    Learning problems
  • 
    Matric not completed.
  • 
    None
  • 
    Other

  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

• Other History of A.D.H.D or Learning Problems*
• Family Medical History*
  • 
    Heart problems as a child
  • 
    Depression or anxiety
  • 
    Motor Tics or Tourettes (nervous twitches)
  • 
    Epilepsy
  • 
    None
  • 
    Other
• Other Family Medical History*

• SCHOOLING HISTORY

• Therapy at school or after-school*
  • 
    Remedial
  • 
    OT
  • 
    Speech therapy
  • 
    Psychological or Play therapy
  • 
    None
  • 
    Other or Current therapy

  Indicate if received additional therapy at school by Occupational therapist(OT), Speech therapist, Remedial teacher. Behavioural therapy by Psychologist.

• Other or Therapy at school*
• Pre-School Problems*
  • 
    Concentration
  • 
    Behaviour and Emotional
  • 
    Task completion
  • 
    Learning
  • 
    None
  • 
    Other

  Indicate if teachers were concerned

• Other Pre-School Problems*

• ASSESSMENTS COMPLETED

  Include all assessments by therapists, school reports and please upload copies.

• Additional information you wish to include

• MCHAT

  Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no for every question. Thank you very much.

• 1. If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)*
  • Yes
  • No
• 2.Have you ever wondered if your child might be deaf?*
  • Yes
  • No
• 3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)*
  • Yes
  • No
• 4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)*
  • Yes
  • No
• 5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)*
  • Yes
  • No
• 6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)*
  • Yes
  • No
• 7.Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)*
  • Yes
  • No
• 8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)*
  • Yes
  • No
• 9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)*
  • Yes
  • No
• 10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)*
  • Yes
  • No
• 11. When you smile at your child, does he or she smile back at you?*
  • Yes
  • No
• 12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)*
  • Yes
  • No
• 13. Does your child walk?*
  • Yes
  • No
• 14. Does your child look you in the eye when you are talking to him or her, playing with him Yes No or her, or dressing him or her?*
  • Yes
  • No
• 15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)*
  • Yes
  • No
• 16. If you turn your head to look at something, does your child look around to see what you are looking at?*
  • Yes
  • No
• 17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)*
  • Yes
  • No
• 18. IDoes your child understand when you tell him or her to do something? (FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”?)*
  • Yes
  • No
• 19. If something new happens, does your child look at your face to see how you feel about it? (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)*
  • Yes
  • No
• 20.Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)*
  • Yes
  • No