Our records are entirely confidential.
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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Are your child's symptoms worse at night or any specific time of day?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 problem?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)
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
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 or birth?
Was a caesarian section performed?
Did 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 5 minutes
Health & Development: Please indicate yes/no to the following
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
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)
Bed wetting beyond the age of 5 years old
Soiling beyond the age of 3 years old
How old was your child when he/she first sat alone?estimate
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How old was your child when he/she first crawled?estimate
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How old was your child when he/she first stood alone?estimate
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How old was your child when he/she first walked without assistance?estimate
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How old was your child when he/she first showed hand preference?estimate
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Which hand does your child prefer?
How old was your child when he/she began to use words?
How old was your child when he/she was toilet trained?Bladder
How old was your child when he/she was toilet trained?Bowel
Does your child (please indicate yes/no)
Have difficulty finding the correct words to use in conversation
Have difficulty getting the correct word out
Put words in the wrong order
Confuse words with similar sounds
Have difficulty pronouncing words or sounds
Hesitate or stop before completing a sentence
Have a stutter
Understands what is said to him/her
Understands stories read to him/her
Talk about events happening or what he/she is doing
Relay a short message
Make good eye contact
Exhibit affection spontaneously
Enjoy playing with others
Flap arms when excited or stressed
Does your child have difficulty with the following tasks: (please indicate yes/no)
Reading (word identification, comprehension, phonics)
Spelling (oral, written)
Writing (legibility, speed, sentence construction, grammar)
Maths (memory of basic facts, concepts)
Organisation (completing class work, homework, morning routine)
Reasoning and problem solving (personal or in school)
Team work
What skill or ability does your child seem to excel in?
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Do you have any other concerns about your child?
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I consent for information about my child to be communicated to my GP and/or other relevant health professionals where appropriate.