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Preschool Child (2-4 years) Medical History Form
Our records are entirely confidential.
PRESCHOOL MEDICAL FORM (2-4YEARS).Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form for your Child.
Nameyour full name
Date of Birthdd/mm/yyy
What is your child's main problem?max 300 characters
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When did it start?max 300 characters
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What do you consider caused this problem?max 300 characters
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Has this problem occurred before and if so when?max 300 characters
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At the onset of the problem, did your child experience any trauma, illness/infection or other significant event?max 300 characters
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What relieves your child's problems?max 300 characters
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What makes your child's problems worse?max 300 characters
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Has your child had any other treatment for the current problems?max 300 characters
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If so what was the diagnosis?max 300 characters
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Who was the practitioner?optional
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Did you find the treatment effective?
Please rate the severity of your child's symptoms10 being the most severe pain (drag button)
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0100
Has your child had any form of surgery or hospitalisation?If yes, please detail
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Is your child currently taking any form of medication?If yes, please list medications.
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Does your child have any other illness, past or present?If yes, please detail
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Has your child had any broken bones, accidents or significant injuriesNo matter how trivial please describe details
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Child's siblingsPlease list name, age, sex and relationship to the child (Full/ Half Adopted/ Step)
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Do any of the siblings have medical problems?
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Pregnancy: Please indicate yes/no to the following
YesNo
Did you smoke during your pregnancy?
Did you drink alcohol during your pregnancy?
Did you take any medication during your pregnancy?
Where there any complications with the pregnancy?
Was a caesarian section performed?
Bid your baby have any bruises or birthmarks?
Where there any other complications during your child's birth?
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What was your child's APGAR ScoreAt 1 minute
What was your child's APGAR ScoreAt 5 minutes
Health & Development: Please indicate yes/no to the following
YesNo
More than two episodes of otitis media (ear infection)
Ventilatory (myringotomy) tubes (grommets)
Visual difficulty
Movement problems
Poisoning or drug overdose
Sleep problems
Hearing difficulty
Poor growth weight/weight gain/failure to thrive
Convulsions/seizures/epilepsy
Difficulty talking
Toe walking
Eating or swallowing problems
Toileting problems
Tics or unusual movement
Run or walk more awkwardly than other children
Headaches not relieved by medication
Headaches in the middle of the night or upon awakening
Lost once- attained skills (language, motor)
How old was your child when he/she first sat alone?estimate
How old was your child when he/she first crawled?estimate
How old was your child when he/she first stood alone?estimate
How old was your child when he/she first walked with assistance?estimate
How old was your child when he/she first showed hand preference?estimate
Which hand does your child prefer?estimate
How old was your child when he/she began to use words?estimate
How old was your child when he/she was toilet trained?estimate
Does your child ( please indicate yes/no)
YesNo
Cry excessively
Rarely or not attempt to communicate
Turn head to distinguish where a sound is coming from
Have difficulty learning new words
Have difficulty following directions
Have difficulty responding appropriately to questions
Understands "Where is mummy"
Point to a body part on request
Follows a two step command most times
Recognises day and night
Understands prepositions (on, under, in front, behind)
Make good eye contact
Exhibit affection spontaneously
Enjoy playing with others
Flap arms when excited or stressed
I consent for information about my child to be communicated to my GP and/or other relevant health professionals where appropriate.pick one!
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