Pre-Appointment Questionnaire

Patient Name

Patient Date of Birth

Day

Month

Year

Parent / Guardian First Name

Parent / Guardian Last Name

Patient History

Born at term? ~39-40 weeks gestation

If no, how many weeks + days?

Uncomplicated delivery?

Details:

Any family history of illness or disease?

Including but not limited to:

Autism Spectrum Disease, Attention Deficit Hyperactitvity Disorder, Intellectual Disability, Specific Learning Disorder (dyslexia, dysgraphia)

Genetic Conditions, Neurological Conditions

Coeliac Disease, Sudden Cardiac Death at young age

Details:

Is the patient up to date with the Western Australian Immunisation Schedule?

Is the patient currently taking any medications? Including supplements, herbal and prescription medication.

Details:

Did the patient reach the developmental milestones appropriate for their age?

Any concerns with the following: Gross Motor, Fine Motor, Speech/Language, Hearing/Vision, Toileting

Details:

Are there any concerns with the patient's growth and/or nutrition? Including poor intake, limited variety etc

Details:

What school does the patient attend?

What school year is the patient enrolled in?

Patient Behaviour

Has a school teacher, educator, or other third party raised concerns regarding patient’s behaviour or attention? (including focus, social skills, academic concerns)

Details:

What are your main concerns regarding the patient? i.e. why did you request an appointment with the Paediatrician?

Include when you notice the concerning behaviours, if other close family members/friends also have concerns regarding these behaviours - inattention, hyperactivity, impulsivity, emotional regulation

When don't you see the concerning behaviours?

What is your priority/main goals to achieve by seeing the Paediatrician?

Does the patient have any concerns?

Details:

Do they notice focus issues, impulse control, specific routines?

Does the patient express behaviours consistent with anxiety, depression, suicidal ideation?

Does the patient:

Snore

Have a problem with daytime sleepiness?

Have a dry mouth on waking?

Wake up unrefreshed in the morning?

Does the patient have a regular bedtime/wake up routine?

On average, how many hours sleep does the patient get at night?

What are the patients screen time habits? (outside of required for school or work)

Other Assessments

Have or does the patient see an Occupational Therapist?

Did they have an assessment or regular ongoing therapy? If yes, please provide details below and upload a copy of progress notes, assessments and/or reports to this form

Have or does the patient see a Speech Therapist/Pathologist?

Did they have an assessment or regular ongoing therapy? If yes, please provide details below and upload a copy of progress notes, assessments and/or reports to this form

Have or does the patient see a Psychologist?

Did they have an assessment or regular ongoing therapy? If yes, please provide details below and upload a copy of progress notes, assessments and/or reports to this form

Have or does the patient participate in other allied health treatments? i.e. Osteopath, Chiropractor Bowen Therapist, Physiotherapist

Details

Has the patient seen the school psychology service or school counsellor for academic or social concerns?

Details: Include any assessments completed and upload a copy to this form

Has the patient had any pathology (blood tests) for Nutrional/genetic screens?

Upload a copy of the Vanderbuilt Questionnaire (if requested) along with any relevant assessments or reports.

If you have any difficulty uploading your documents, please send them via reply email to reply to admin@paediatrichq.com.au