Our records are entirely confidential.
  • PRIMARY SCHOOL AGE MEDICAL HISTORY FORM (5-12 YEARS). 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 problem?*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 or birth?
    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
  • 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)
    Bed wetting beyond the age of 5 years old
    Soiling beyond the age of 3 years old
    26
  • How old was your child when he/she first sat alone?*estimate
    27
  • How old was your child when he/she first crawled?*estimate
    28
  • How old was your child when he/she first stood alone?*estimate
    29
  • How old was your child when he/she first walked with assistance?*estimate
    30
  • How old was your child when he/she first walked without 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?*Bladder
    35
  • How old was your child when he/she was toilet trained?*Bowel
    36
  • Does your child ( please indicate yes/no)*YesNo
    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
    37
  • Does your child have difficulty with the following tasks: (please indicate yes/no)*YesNo
    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)
    Sports
    Coordination
    Team work
    38
  • What skill or ability does your child seem to excel in?*
    39
  • Do you have any other concerns about your child?*
    40
  • 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
    41
  • 42
  • Date*make a booking
    43