Medical History Form

Pre-appointment Questionnaire
Child's Name*

First NameLast Name
Child's date of birth
What are your major concerns that you would like addressed during the consultation?
What were your child's measurements at birth?
Weight Height Head Circumference
What are your child's measurements most recently?
Weight Height Head Circumference
Please detail your current feeding - breast/bottle/solids including feed volumes or any difficulties?
Do you have any concerns about your child's vomiting or stools?
Are your child's immunisations up to date?

YesNo
Did your child receive Vitamin K and Hepatitis B at birth?

YesNo
Are you giving any regular medications or treatments (including over the counter remedies) to your child?
Is there a family history of any childhood problems?

Hip problemsHeart issuesBleeding disordersCataractsOther
Were there any issues in pregnancy or any medication required?

Thyroid issuesVitamin DBreech positioningOther
Please list the names, ages and any significant medical concerns with any siblings?
What developmental milestones has your child achieved?
Do you have any concerns about your child's:

VisionHearingDevelopmentOther
Does your MCHN or GP have any concerns about your child?
Are there any other medical or social factors that I need to be aware of that impact the wellbeing of your child?
By signing this document, I understand and consent to:
·       the care provided to my Child by the paediatrician at the request of my GP or obstetrician
·       the collection and storage of personal medical information and the distribution of this information to relevant parties where necessary
·       electronic communication using my email address
·       the fee for this paediatric service
·       communication with other health providers
Clear
Full Name
Should be Empty:

Pre-appointment Questionnaire