Paediatric History Form

Please complete and submit the below form.

Paediatric History Form

Patient Information

Gender
Language
ATSI
Present Health Concerns

Parent/Guardian

Emergency Contact Details

Next Of Kin Details

Is the next of kin, the same as your emergency contact? (If yes, you do not need to fill out this section).

Referring Doctors Details

Medicare Details

Do you use a different name on your Medicare card?

Private Health Insurance

Do you have private health insurance?

Medications

Please list all prescription and non-prescription medications, vitamins, home remedies, birth control, herbs etc.
Personal Medical History
Personal Surgical History

Hospitalisations

Please list all prior hospitalisations and dates.
Immunisations

Pregnancy & Births

Is this child yours by
Pregnancy
Weeks
Medical problems during pregnancy?
Problems during labour and delivery?
Any alcohol exposure in pregnancy?
Method of Delivery
Resuscitation after the child’s birth?
grams
cm
cm
Special Care Nursery Admission
Any birth defects?
Transfer to tertiary care centre
Did your baby pass the universal hearing test
Was you child high risk for hip dysplasia at birth?
Any concern in growth in first one year of life?
Is your child circumcised? (For Male Patients Only)

Sleep

hours
Does your child take nap every day?
Any sleep problems?
Does your child take a long time to fall asleep?
Does your child snore at night?
Does your child wake up early?
Sleep walking?
Sleep talking?
Night terror?
Night-time seizures?
Bed wetting?

Nutrition & Feeding

Type of feeding at newborn
Any difficulties in establishing solids?
Any period of unsettledness, excessive crying in infancy?
Any persistent vomiting in infancy?
Any family member with eating disorder or feeding intolerance
Body image issue?
Recent purposeful weight loss?
Is food an important part of your child’s life?
Excessive weight gain?

Development

Any concern about your child’s gross motor skill such as rolling over, sitting, walking, running, jumping and riding a tricycle or bike?
Any concerns about your child’s ability to scribble, building blocks, handwriting, use of scissors, dressing, feeding , kicking and catching the ball?
Any areas of concerns about language or speech development?
Difficulty in understanding and following instructions
Difficulty in expressing with clarity of words
Difficulty in use of non-verbal facial gestures?
Difficulty in ability to modulate voice?
Tendency to repeat words or inventing new words?
Difficulty in ability to chat/ back-and-forth conversations?
Difficulty in use of language appropriate for the social situation?
Any areas of concerns about socialisation?
Difficulty in social overtures?
Difficulty in playing imaginatively or in a group setting?
Difficulty in eye contact?
Difficulty in making friends?
Difficulty in recognising emotions in other people?

Behaviour

Do you have concerns about your child’s behaviour at home or in groups with other children? Also please select from the following list if your child has any issues such as

Social History

Are the patient’s parents
Do any household members smoke?
An exposure to domestic violence
House
Any adverse childhood experience or trauma?
Any involvement of Child Protection?
Would you like to speak with the physician regarding your child’s
hours
hours
hours
Do you have any concerns about lead exposure due to having an old home, or because of plumbing, and peeling paint?
Is your child shared cared?
Parental separation?

Who lives at home with the patient?

School History

Attending school/preschool?
Do you have concerns about your child’s behaviour or learning at school?
Any concerns about relationships with teachers or other students?
If more than 4 years old: does your child have a best friend?
Does your child play any sports outside the school?
minutes

Family History

Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandfather
Paternal Grandmother
Does anyone in the family with the following issues?

Other Information

Attach Documents

Maximum file size: 10MB

Allowed files, Pdf, Doc, Docx, Png, Gif and Jpeg.

Collection Of Health Information & Consent

As a patient of our medical practice, we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. We aim to protect the privacy and secure storage of your health information.
We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and sign were indicated below. Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals. Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient care and teaching.

For research and quality assurance activities to improve individual and community health care and practice management. Usually, information that does not identify you is used but should information that will identify you be required you will be informed and given the opportunity to “opt out” of any involvement. To comply with any legislative or regulatory requirements e.g., notifiable diseases. For reminder letters which may be sent to you regarding your health care and management.

NOTE: You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.

Read it carefully and sign at the bottom,
Gippsland Specialist Clinic is a private clinic and not a bulk-billing practice.
Therefore, there may be out-of-pocket cost involved with your doctor’s visit. It is encouraged that the patients discuss doctor’s fees prior to their visits, to avoid any confusion.
There are discounts available for patients holding Pension card/ Healthcare Card or depending on individual situation. It is expected that the patients will pay their fees in full before they leave the clinic. Any invoice generated in relation to the patient’s fees will be mailed to the patient’s nominated address or emailed to him/ her. We expect payment of this invoice within 2 weeks of time.

Collection of Information Consent
Communication and patient portals consent