Brave Kids Clinic Pre- Appointment Questionnaire
This pre-appointment questionnaire will help us better understand your child’s needs, preferences, and any concerns before their visit to the Brave Kids Immunisation Clinic. Your responses will help us create a calmer, more supportive, and more comfortable experience for your child and family.
How would you describe your child's previous vaccination experiences?
Very positive
Mostly positive
Neutral
Mostly difficult
Very difficult
Not applicable / first vaccination
Other
What is the biggest challenge for your child when receiving vaccinations? (Select all that apply)
Fear of needles
Anxiety before the appointment
Waiting room environment
Sensory sensitivities
Being touched
Seeing medical equipment
Hearing other children cry
Separation from parent/carer
Previous negative experience
Other
What has worked well during previous vaccinations or medical procedures?
Are there any staff behaviours or approaches that increase your child's anxiety and should be avoided?
Is there anything that healthcare staff have done in the past that helped your child feel safe, calm, or supported?
Sensory Accommodations
Which environmental adjustments would help your child feel more comfortable? (Select all that apply)
Dimmed lighting
Quiet waiting area
No music
Soft music
Reduced scents/fragrances
Fidget toys available
Weighted lap blanket and/or plush
Noise-cancelling headphones
Visual distractions (TV, tablets, bubbles)
Other
We have a clinic dog, Moss. Would your child like them present in the clinic? You would also be welcome to bring your own animal from home if preferred.
My child would like Moss present
We would like the option of bringing our own support animal
No animal preferred
Other
Does your child use any calming or regulation tools that they would like to bring with them?
Is there anything else we can do to accommodate your child to ensure a smooth process and comfortable environment?
Communication
What communication style works best for your child?
Detailed explanations
Simple explanations
Visual supports
Demonstrations before the procedure
Advance warning before each step
Minimal discussion
Varies / depends on the situation
Other
How would your child prefer to spend their waiting time before their vaccination? (Select all that apply)
Wait in the car until called
Go straight into a treatment room on arrival
Wait in a quiet and isolated waiting area
Wait in the general waiting room
Have access to sensory/fidget toys
Read a book or use a device
Spend time with Moss (clinic dog) or own pet
Other
Would your child prefer:
To know exactly when the needle is happening
To be distracted and not told the exact moment
Depends on the situation
Other
Is there anything else we can do before the appointment to help your child feel prepared? (Select all that apply)
Socials story with photos of the clinic
Meet the nurse beforehand
View the vaccination room before the appointment
Receive information by email beforehand
Phone call prior to the appointment
Other
Would you like a pre appointment phone call with the nurse for you or your child to discuss any of the above or other information that might be helpful?
Yes
No
Other
Would you like to visit the practice before your appointment to become familiar with the space?
Yes
No
Other
Please share any additional comments, suggestions, concerns, or ideas that may help us create a safe, comfortable, and positive vaccination experience.
Patient details
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Patients Date of Birth
Preferred/usual GP
Your details (If someone other than the patient is completing this form on behalf of the patient)
First Name
Last Name
Email
example@example.com
Contact Number
Please enter a valid phone number
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