HEMO (M / 14-09-2006)
Initials | HEMO |
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Birthdate | 14-09-2006 (9 year(s) old) |
Gender | Boy |
Date for an appointment with the doctor | none |
Group | Coagulation diseases EKZ |
Reporter | 17-04-2015 |
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This list has been completed by: | Mother |
Family | 17-04-2015 |
What is your date of birth? | 19-04-1974 |
What is your marital status? | Single |
What is the country of birth of your (ex) partner (the father or mother of your child)? | The Netherlands |
How many children do you have? | 3 |
Optional explanation: | efwefewf |
How many children are currently living with you and how old are they? | There is / are 3 child(ren) younger than 4 years old |
What is the current work situation for yourself? (more than one answer possible) | Sick leave |
Sports club | 17-04-2015 |
Is your child involved in a sports club? (such as soccer, judo, horseback riding) | No |
Physical | 24-04-2015 | 14-04-2016 |
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It is hard for me to walk more than one block | Never | Almost never |
It is hard for me to run | Sometimes | Sometimes |
It is hard for me to do sports activity or exercise | Almost never | Often |
It is hard for me to lift something heavy | Sometimes | Almost never |
It is hard for me to take a bath or shower by myself | Sometimes | Never |
It is hard for me to do chores around the house | Often | Never |
I hurt or ache | Almost never | Sometimes |
I have low energy | Almost never | Almost never |
Emotional | 24-04-2015 | 14-04-2016 |
I feel afraid or scared | Never | Almost never |
I feel sad or blue | Almost never | Almost never |
I feel angry | Sometimes | Sometimes |
I have trouble sleeping | Never | Almost never |
I worry about what will happen to me | Never | Almost never |
Social | 24-04-2015 | 14-04-2016 |
I have trouble getting along with other kids | Never | Never |
Other kids do not want to be my friend | Never | Never |
Other kids tease me | Never | Never |
I cannot do things that other kids my age can do | Never | Sometimes |
It is hard to keep up when I play with other kids | Never | Almost never |
School | 24-04-2015 | 14-04-2016 |
It is hard to pay attention in class | Never | Never |
I forget things | Never | Never |
I have trouble keeping up with my schoolwork | Never | Almost never |
I miss school because of not feeling well | Never | Sometimes |
I miss school to go to the doctor or hospital | Never | Sometimes |
Reporter | 17-04-2015 |
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This list has been completed by: | Mother |
Prosocial | 17-04-2015 |
Considerate of other people's feelings | Somewhat true |
Shares readily with other children (treats, toys, pencils etc.) | Somewhat true |
Helpful if someone is hurt, upset or feeling ill | Not true |
Kind to younger children | Somewhat true |
Often volunteers to help others (parents, teachers, other children) | Somewhat true |
Hyperactivity | 17-04-2015 |
Restless, overactive, cannot stay still for long | Certainly true |
Constantly fidgeting or squirming | Not true |
Easily distracted, concentration wanders | Somewhat true |
Thinks things out before acting | Somewhat true |
Sees tasks through to the end, good attention span | Not true |
Emotional | 17-04-2015 |
Often complains of headaches, stomach-aches or sickness | Certainly true |
Many worries, often seems worried | Somewhat true |
Often unhappy, down-hearted or tearful | Somewhat true |
Nervous or clingy in new situations, easily loses confidence | Not true |
Many fears, easily scared | Not true |
Behavior | 17-04-2015 |
Often has temper tantrums or hot tempers | Somewhat true |
Generally obedient, usually does what adults request | Certainly true |
Often fights with other children or bullies them | Not true |
Often lies or cheats | Certainly true |
Steals from home, school or elsewhere | Somewhat true |
Peers | 17-04-2015 |
Rather solitary, tends to play alone | Not true |
Has at least one good friend | Not true |
Generally liked by other children | Not true |
Picked on or bullied by other children | Not true |
Gets on better with adults than with other children | Somewhat true |
Comments | 17-04-2015 |
Do you have any other comments or concerns? | wefwefwefew |
Difficulties | 17-04-2015 |
Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people? | Yes, minor difficulties |
How long have these difficulties been present? | 1-5 months |
Do the difficulties upset or distress your child? | Only a little |
Home life | Not at all |
Friendships | A great deal |
Classroom learning | Only a little |
Leisure activities | A great deal |
Do the difficulties put a burden on you or the family as a whole? | Only a little |
School | 14-04-2016 |
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What type of education are you currently in? | Regular primary school |
In what grade are you? | 7 |
Have you ever had to double a grade? | No |
How many schooldays have you missed in the past three months? | 5 |
Questions | 14-04-2016 |
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Is there anything you would like to ask/tell the person with whom you have an appointment? | No |