MCHAT FORM SCREEN FOR ASD

MCHAT Form 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.

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, 031-1000 474 email: assessment@courses.drflett.com

Completion Date

Child's Name(Required)

First Last

Gender(Required)

Female

Male

Date of Birth of Child(Required)

Mother(Required)

First Last

Father(Required)

First Last

Cell Phone Parents(Required)

Email Parent(Required)

Enter Email Confirm Email

Name of School(Required)

Name of Teacher(Required)

First Last

Cell Phone Teacher

Grade(Required)

Please enter a number from 000 to 12.

Email of School or teacher(Required)

Therapists seen(i.e. psychologist etc) copy to

First Name

Last Name

Discipline

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(Required)

Please include medical as well as psychological

Other Problems during pregnancy(Required)

Birth Weight(Kg)(Required)

Please enter a number from 1 to 5.

Colic or Cramps in the first 3 months(Required)

yes

Other

Difficulty with excessive crying or sleeping problems.

Problems During Birth(Required)

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

Parental Concerns

Behavior Problems(Required)

Include concerns experienced at school and outside of school frequently.

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(Required)

Family Intact

Divorced

Other

History of A.D.H.D or Learning Problems(Required)

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(Required)

Family Medical History(Required)

Other Family Medical History(Required)

SCHOOLING HISTORY

Therapy at school or after-school(Required)

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

Other or Therapy at school(Required)

Pre-School Problems(Required)

Indicate if teachers were concerned

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?)(Required)

Yes

2.Have you ever wondered if your child might be deaf?(Required)

Yes

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?)(Required)

Yes

4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)(Required)

Yes

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?)(Required)

Yes

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)(Required)

Yes

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)(Required)

Yes

8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)(Required)

Yes

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)(Required)

Yes

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?)(Required)

Yes

11. When you smile at your child, does he or she smile back at you?(Required)

Yes

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?)(Required)

Yes

13. Does your child walk?(Required)

Yes

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?(Required)

Yes

15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)(Required)

Yes

16. If you turn your head to look at something, does your child look around to see what you are looking at?(Required)

Yes

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”?)(Required)

Yes

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”?)(Required)

Yes

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?)(Required)

Yes

20.Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)(Required)

Yes

Giving you the skills to support your child.

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New Patient Schooling Assessment Form Dr. John Flett. Hillcrest Private Hospital. www. schoolingassessment.com, 031-1000 474 email: assessment@courses.drflett.com

Previous Medical History

Parental Concerns

FAMILY HISTORY

SCHOOLING HISTORY

ASSESSMENTS COMPLETED

MCHAT

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