parent questionnaire - all about kids
TRANSCRIPT
Parent QuestionnairePERSONAL DETAILS
Child’s Details: Full Name:
Address:
Date of Birth: Age: Gender: Male Female
Caregiver Details: Caregiver /1 Address: Mobile:
Caregiver /2 Address:
School/Childcare: Grade:
School Address:
Teacher/Contact: Position:
Phone: Fax:
Email:
Hours & Days Attending:
School Concerns:
General Practitioner: Contact Details:
REASON FOR SEEKING SERVICES
What are your main concerns regarding your child?
What do you want to achieve for your child by coming to All About Kids Occupational Therapy?
BIRTH HISTORY
Did you have any problems during pregnancy? Yes No
If YES, please give details:
Was the birth? Premature Full Term Overdue Weeks:
Type of delivery: Normal Caesarean Breech Other Details:
Length of Labour: Normal Prolonged Details:
Did your baby require? Oxygen Tube Fed Transfusions NICU/Special Care Nursery
Details and duration:
Was your child? Breast Fed Bottle Fed Both How long:
Thank you for taking the time to complete this document. Your clinician, and All About Kids, will appreciate your information. Please read and fill out the whole document where
relevant, and check the box at the bottom of page 8.
[email protected] www.allaboutkids.com.au(07) 3262-6009Shop 2, 33 Lisson Grove Wooloowin, 4030
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
Mobile:
Other:_________
Caregiver /1 Email: Caregiver /2 Email:
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MEDICAL HISTORY
Diagnosis:
Medication:
How often does your child get sick? Frequently Occasionally Never
Does your child have any allergies?
Yes No Details:
Has your child experienced any of the following?
Snoring/mouth breathing Bad breath
Ear infections Hyperactivity
Head injury Sleep challenges
Fractured limbs Family history allergies
Frequent daydreaming Eczema/skin rashes
Reflux Dark circles (purple shiners) under eyes
Constipation/diarrhoea Asthma/respiration problems
Bloating/gas/tummy discomfort Other
Please list any surgeries or procedures your child has undergone with approximate dates:
NUTRITION AND FEEDING HISTORY
Do you have concerns with any of the following
Mealtime behaviours Details:
Dietary variety Details:
Dietary quality Details:
Response to new foods Details:
Breast feeding (bottle feeding) Details:
Transition to solid foods Details:
With biting, chewing or managing lumps of foods Details:
Other feeding concerns Details:
[email protected] www.allaboutkids.com.au(07) 3262-6009Shop 2, 33 Lisson Grove Wooloowin, 4030
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
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MEDICARE DETAILSMedicare No.: _______________________________ Medicare Expiry Date: _______________Childs' Ref. No.: ______ Main Claimant's (Parents) Ref. No.: _______ Main Claimant's (Parents) D.O.B._______________
TREATMENT HISTORY
Discipline Name & Location Reason Last seen
Paediatrician
Psychologist
Speech Pathologist
Occupational Therapist
Physiotherapist
Dietician/Nutritionist
Other
SOCIAL HISTORY
In order for us to best work with you, we need to know a little about your family, please answer the
questions below. If you are unsure how to answer, feel free to leave those sections for your first session.
Are there any formal custody arrangement in place? Yes No
If YES, please give details:
Please provide details of your family: (name, gender, age, half/step siblings)
Please provide details of any relevant family medical history: (autism, learning problems, mental health problems)
Please provide details of any relevant family history which might impact on your child: (divorce, separation, recent moves)
DEVELOPMENTAL HISTORY
At what age did your child achieve the following milestones?
Hold head up: Sit independently: Roll over:
Creep: Crawl: Stand alone:
Point: Babble: Wave:
Hand Preference First word: Combining words:
[email protected] www.allaboutkids.com.au(07) 3262-6009Shop 2, 33 Lisson Grove Wooloowin, 4030
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
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VISUAL & MOTOR SKILLS
Please tick any difficulties your child experiences:
Using scissors Jumping
Playing with small toys Using cutlery
Completing puzzles Doing Shoelaces
Learning to swim Holding a pencil
Riding a bike Writing/drawing
Catching a ball Pumping self on swing
Kick a ball Learning new motor skills
SPEECH AND LANGUAGE SKILLS
Please tick any difficulties your child experiences:
Reading out loud Spelling
Understanding written information Telling a story
Being understood by others Makes speech sound errors
Fluency/stuttering Other
If your child is not using speech to communicate, can you describe how they communicate their needs and wants:
Crying/Body language Details:
Gestures (e.g. pointing, mime) Details:
Using Sign language Details:
Using Pictures/symbols Details:
Using a voice output device/ipad Details:
SOCIAL EMOTIONAL SKILLS
Please tick any difficulties your child experiences:
Mostly quiet Overly active Tired easily Impulsive
Restless Stubborn Resistant to change Sensitive
Talks constantly Fights frequently Temper tantrums Wets Bed
Fearful Frustrated easily Poor Attention Perfectionist
Separation difficulties Immature Over affectionate Anxious
Making Friends Keeping friends Bullies other children Bullied at school
[email protected] www.allaboutkids.com.au(07) 3262-6009Shop 2, 33 Lisson Grove Wooloowin, 4030
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
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Problem solving Managing conflicts Understanding Jokes Other
Please list any other social emotional difficulties your child experiences:
SENSORY PROCESSING
Please tick the response that best describes your child’s behaviour. Add any additional comments where
appropriate.
Frequently Sometimes Never Comments
Seems to be in constant motion or is unable to sit still for an activity
Has trouble concentrating or can’t stay on task
Seems to always be running, jumping, or stomping rather than walking
Bumps into things or frequently knocks things over
Reacts strongly to being bumped or touched
Avoids messy play and doesn’t like to get hands dirty
Hates having hair washed, brushed or cut
Resists wearing new clothing or is bothered by tags or socks
Distressed by loud or sudden sounds such as a siren or a vacuum
Hesitates to play or climb on playground equipment
Difficulties with balance
Mood variations, outbursts and tantrums
Avoids eye contact
Has trouble following multistep instructions
Fussy eater, often gags on food
Reacts strongly to smells
High pain threshold
[email protected] www.allaboutkids.com.au(07) 3262-6009Shop 2, 33 Lisson Grove Wooloowin, 4030
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
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[email protected] www.allaboutkids.com.auShop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
Your signature (in the designated location below) indicates that you fully understand and hereby grant permission to All About Kids practitioners to (tick all that apply):
o contact relevant professionals such as school/kindy staff and other health professionalssuch as my child’s GP or other medical specialist if required, as part of the informationsharing process to assist with the allied health services offered through AAK. This mayalso include another practitioner at AAK.
o correspond with myself and relevant professionals via email and phone regarding mychild when appropriate.
o correspond with my child’s other parent/guardian _______________ via email or phoneregarding my child when appropriate.
o photographic, audio or video material of my child to be collected during clinical sessionsto assist in their assessment or treatment.
o contact the following professionals and other agencies below if required, as part of thedata and information gathering process to assist with the allied health services offeredthrough AAK.
Organisation /Specialist
Organisation Name/Practice Name/School Name Contact Person
Parents/Guardian
Contact Details e.g. Phone Number or Email Initials
GP
Medical Specialist e.g. Paediatrician
School/Childcare
Allied Health Professional
Parent/Guardian Consent Form Childs Name:_________________ Childs Date Of Birth:________________
Privacy Information: At All About Kids we only collect information about your child for the purposes of providing appropriate services to your child. We will not share the information with anyone without your knowledge or consent.
Other:__________
________________
Please fill in each of the boxes below if relevant.
All About Kids can contact and leave messages for me on the phone numbers provided below:
1____________________2____________________
All About Kids can email communications to me on ____________________ or _________________ - including new services offered, helpful newsletters and feedback surveys: Yes No
Parent/Guardian Name: ________________________
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Payment & Cancellation Policy
If you need to cancel or postpone your appointment, please provide All About Kids Australia Pty Ltd with
at least one working days’ notice, otherwise you will be charged the full cost of the session. A working day
is defined as Monday to Friday 8am to 5pm and Saturday 8am to 12pm.
From 1st June 2016, cancellation fees will be calculated as follows:
1. For appointments cancelled more than one working day prior to the appointment No Charge
2. For appointments cancelled less than one working day prior to the appointment Full Fee
3. Non-attendance without notice Full Fee
We recognise that there are exceptional circumstances where this fee may not apply.
All About Kids Australia Pty Ltd reserves the right to waitlist future bookings when clients have had two or
more cancellations with less than one working day/s notice.
NOTE: The cancellation fee cannot be claimed through Medicare, HCWA or Better Start Package funding.
Fee Payment
If payment is not made on the day of an appointment, or if a cancellation fee is owing, an invoice will be
emailed to you. The appointment fee or cancellation fee will be charged to the credit card detailed in the
Credit Card Authorisation below and a paid invoice will be emailed to you for your records. All outstanding
fees must be paid prior to the provision of further services from All About Kids Australia Pty Ltd.
Late Attendance To Appointments Policy
We understand that there are times when children and families arrive late for appointments. In order to
respect clients with subsequent appointments in the day, your appointment must finish on time, and the
full appointment fee will still be charged.
Credit Card Authorisation
At your child's initial or subsequent sessions reception staff may ask for your credit card details. The credit card details will be kept on file and will be charged to cover outstanding fees as described in the above
fee payment policy. Credit Cards will be kept confidential on our secure practice system. An invoice
will be issued after this card has been charged.
I have read and understood the above fee payment policy and agree to provide my credit card
details when requested in accordance with the above fee payment policy:
Policy Amended: 1/11/2016
[email protected] www.allaboutkids.com.auShop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
Initials: __________
Yes
No
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YES NO
Parent Consent
Do you have a ‘Parenting Agreement” in place?
If yes, have you provided a copy to All About Kids? YES NO
1. I give permission for information regarding my child _________________________ be shared
with________________________________(Parent). YES NO
2. I give permission for information shared between myself and my child’s practitioner to be
disclosed to ________________________________(Parent) upon their request. YES NO
3. Are there any other legal lodgements All About Kids should know about that are relevant to
the child / children? i.e. A. V. O.
If yes, please provide details:
[email protected] www.allaboutkids.com.auShop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009
6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
Clinic:
Clinic:
Forms and Policies Agreement
I understand that signing in the designated area below confirms that I have completed, read and understood the forms and policies in this document. The information I have provided is correct and I agree to the permissions and cancellation policies as part of the service provided by All About Kids.
Client's Name: Parent/Guardian First-Last Name: Date:
*Signature: __________________________________
*If you are unable to provide a digital signature please print this document out and sign it and emailit back or sign it and hand it to reception when you arrive for your appointment.
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