PAEDIATRIC NEW CLIENT INTAKE FORM

This information helps us to provide the best possible assessment and treatment plan for your child. We respect your privacy. Please see our Privacy Policy.

Name of child

First Name

Last Name

Date of Birth

Gender

Male

Female

Name of Parent/Guardian

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Occupation

Referred By

How did you find out about us?

Usual GP / Practice Address

Your child's usual GP

Your child's Paediatrician?

(If applicable)

Private Health Fund (If applicable)

Who is your Private Health Fund provider?

Past Medical History

Has your child been diagnosed with any medical conditions?

What are your main concerns for your child?

At how many weeks was your child born?

Were there any complications during pregnancy?

E.g. gestational diabetes, high blood pressure, growth restriction.

How was your child born?

E.g. Normal delivery, C-section.

Has your child had any medical problems or surgeries since birth?

Does your child take any regular medications?

Have your child's hips been screened?

Does your child have any issues with vision, hearing, feeding or sleeping?

Has your child been seen by any other therapists?

Declaration

BY SUBMITTING THIS FORM; - You declare that the information supplied is correct to the best of your knowledge - That all debts owed in relation to the provision of services are your responsibility - You give us permission to use your information to communicate with relevant stakeholders (doctors/case managers etc) and for occasional marketing purposes This information helps us to provide the best possible assessment and treatment plan for your child

I Agree