Developmental Form

This form is designed for the parent/guardian of a child to complete. By completing this form, the parent/guardian is providing valuable information regarding the child under their care. This information will be used by the ADHD Specialist whilst carrying out a ADHD assessment.

Name of person completing this form:

How did you hear about us?

Patient Details

Name of patient

Date of Birth of patient

Gender of patient

Patients Mothers name

Patients Mothers occupation

Patients Fathers name

Patients Fathers occupation

Other carers

Name and address of School or Nursery

Languages spoken at home

Name & Address of the patients GP Surgery

Are you the responsible Guardian of the patient?

If you are the responsible guardian of the patient, do you give consent for 'ADHD Certify' to contact the patients GP Surgery with the outcome of their ADHD Assessment?

Background

Parents concerns: Describe why you are seeking an ADHD assessment for your child?

- When did you first become concerned about your child?

-What is your main concern?

- What has helped so far?

Have school staff / other professionals raised any concerns about your child (if so please document them here):

Birth/pregnancy history

Describe any complications during the pregnancy/birth of the child: (Some topics to consider are: maternal health, drugs/ alcohol/ smoking, prematurity/ birth complications, special care in hospital)

Post Natal History

Did the child experience any complications in the first 6 months of life? (in your answer consider the following areas: sleep patterns, feeding habits, temperament, maternal health)

Family history / Social history

Who lives at home?

Can you identify any details within your families medical/mental health history which concerns you in regards your child's symptoms?

For example, in the child's family history (blood relatives) is there any evidence of:

- ADHD - Autism Spectrum Disorder

- Language and communication problems

- Learning concerns/disability

- Mental Health Difficulties

Have any significant events occurred in the child's life which you feel may have had a significant impact in either the child's mental or physical health?

Current health and past medical history

Please describe the child's general health:

Include the following details: Any diagnosis, investigations, medications, admissions, surgeries, allergies, head injuries, cardiac problems, tics/ faints. Funny turns.

Hearing and vision:

Were you ever concerned about your child’s hearing?

How would you describe the child's diet and appetite?

In your answer pay particular attention to the following:

- fussiness around food

- Will the child try new foods?

- Does the child have a preference for food in certain packaging/brands?

- When did the child transition from milk to solids and how did this process go?

- Was the child breastfed?

Sleep: Tell us about how your child sleeps:

- Have you ever felt your child's sleep patterns were unusual (and if so, please describe these patterns)?

- Does the child sleep through the night?

- If your child wakes up in the night, are they easy to settle?

- Do they sleep alone? (and if so, from what age did this start?)

Mental Health?
Has the child experienced any difficulties with mood problems, anxiety, obsessions or any other psychological traits you consider unusual.

Has your child ever expressed any desire to harm themselves or end their life? (If so, describe these events and any relevant details surrounding these events).

Has the child every used illegal drugs, drank alcohol, smoked cigarettes' or used vaping devices?

Patients Height (in cm)

Note: if you are unaware or unable to check the height of the patient, please visit your local pharmacy or GP Surgery to get an accurate reading.

PatienWeight (in Kg)

Note: if you are unaware or unable to check the weight of the patient, please visit your local pharmacy or GP Surgery to get an accurate reading.

Patients Blood Pressure (for example, 120/60)

Note: if you are unaware or unable to check the blood pressure of the patient, please visit your local pharmacy or GP Surgery to get an accurate reading. For children aged between 5-16 years of age, the blood pressure must be checked by your GP or medical personnel skilled in doing so.

Patients Heart Rate (number of heart beats per minute)

Note: if you are unaware or unable to check the heart rate of the patient, please visit your local pharmacy or GP Surgery to get an accurate reading.

Does the child have any diagnosed medical conditions or diseases? (Please List)

Does the child have any allergies?

Does the child have any allergies (if no allergies, write NA)

Please list all current medications (if any) the child is taking? (if the child is taking no medications then write 'None')

Does the patient suffer from any of the following? (select as appropriate)

Note: These questions are required to ensure the patients safety in the event they are prescribed medication by our service.

Developmental Milestones

Language Development :

When did he/she use first words? When did they use sentences? Did they ever develop skills (e.g. speech) and then lose them again? Referred to Speech therapy?

Interaction:

What age did your child first smile?

What age did your child begin to put their arms up to be lifted?

What age did your child start showing interest in other people?

Does your child like to be tickled or play lap? games?

Motor Development:

- When did he/she sit unsupported?

- Did he/she crawl/ bottom shuffle?

- When did he/she walk, run, climb, ride a bike?

- Is he/she clumsy?

- History of accidents/ falls?

- Does he/she experience Tics or abnormal motor movements or mannerisms

Awareness of danger? Is your child aware of physical dangers and social dangers (e.g.stranger danger)

Self-help skills:

- Does he/she use the toilet independently?

- Does he/she dress and undress themselves?

- Is he/she perform tasks such as feeding themselves at meal times?

Social development:

Did they like to be cuddled, eye contact, social smiling, response in play, babbling, putting arms up to be lifted

Your Child as a toddler

To what extent did your child need to be near you all the time?

How did your child cope with separation, e.g. babysitter/going to Gran’s/playgroup/nursery?

How did he/she get on with other children at nursery?

Was there anything usual about his/her play?

Playing with toys in unusual ways. Playing with objects rather than toys, only playing with certain toys

Did he/she use pretend play?

Imitating what others were doing, using toy animals or figures, pretend tea parties etc.

Before speaking, did he/she point to something to show you what he wanted?

Before speaking, did he/she use pointing, gesture or miming to show you what he wanted or how he was feeling?

If he/she was interested in something, would they want to share it with you?

i.e. by pointing at a dog or plane or bring something to you to look at? Would he/she bring something he/she had built or drawn to show you?

Would he/she come to you for help if he/she were struggling to do something?

Other comments about your child as a toddler:

At School

Nursery?

How is your child getting on with school work? Are there any specific areas of concern?

Can your child follow the school routine? Stand in line? Eat in the cafeteria? Use school toilets?

How is their behaviour at school?

How does he/she get on with other children? Can he/she work in a group?

Any problems with school attendance?

How did he/she cope with any changes to the routine- change of teacher, change of class or plan for the day?

Any other comments about school?

Attention

What is their concentration like? At home and at school; do they make lots of mistakes, do they rush?

Can they sit to watch a film/TV programme/read a book? Will they sit still while doing this?

Is there anything that your child can sit still at for a long period of time? How long? Do they finish things they have started?

Are they dreamy, forgetful? Do they lose things?

How organised is your child? Do they avoid tasks that require effort? More than other children?

Does he/she follow/listen to instructions? Is that different with other people? Does your child listen when spoken to directly?

Is your child easily distracted?

Has your child always been like this?

Activity levels and impulsivity

Is your child physically restless/ fidgety? Do they run, climb, jump a lot in situations when it is not safe or appropriate? Give examples