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.
    0
  • Name*
    1
  • Date of Birth*dd/mm/yyy
    2
  • What is your child's main problem?*max 300 characters
    3
  • When did it start?*
    4
  • What do you consider caused this problem?*
    5
  • Has this problem occurred before and if so when?*
    6
  • At the onset of the problem, did your child experience any trauma, illness/infection or other significant event?*
    7
  • Are your child's symptoms worse at night or any specific time of day?*
    8
  • What relieves your child's problems?*
    9
  • What makes your child's problems worse?*
    10
  • Has your child had any other treatment for the current problems?*optional
    11
  • If so what was the diagnosis?*
    12
  • Who was the practitioner?*optional
    13
  • Did you find the treatment effective?*
    Yes
    No
    14
  • Please rate the severity of your child's symptoms*10 being the most severe pain (drag button)
    Pain0
    15
  • Has your child had any form of surgery or hospitalisation?*If yes, please detail
    16
  • Is your child currently taking any form of medication?*If yes, please list medications.
    17
  • Does your child have any other illness, past or present?*If yes, please detail
    18
  • Has your child had any broken bones, accidents or significant injuries*No matter how trivial please describe details
    19
  • Child's siblings*Please list name, age, sex and relationship to the child (Full/ Half Adopted/ Step)
    20
  • Do any of the siblings have medical problems?*
    21
  • 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?
    22
  • Where there any other complications during your child's birth?*
    23
  • What was your child's APGAR Score*At 1 minute
    24
  • What was your child's APGAR Score*At 5 minutes
    25
  • How many days after birth did you take the baby home?*
    26
  • 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)
    27
  • How old was your child when he/she first sat alone?*estimate
    28
  • How old was your child when he/she first crawled?*estimate
    29
  • How old was your child when he/she first stood alone?*estimate
    30
  • How old was your child when he/she first walked with assistance?*estimate
    31
  • How old was your child when he/she first showed hand preference?*estimate
    32
  • Which hand does your child prefer?*
    33
  • How old was your child when he/she began to use words?*
    34
  • How old was your child when he/she was toilet trained?*
    35
  • 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
    36
  • What skill or ability does your child seem to excel in?*
    37
  • Do you have any other concerns about your child?*
    38
  • I consent for information about my child to be communicated to my GP and/or other relevant health professionals where appropriate.*
    I give consent
    I do not give consent
    39
  • 40
  • Date*make a booking
    41