Registration Form

Administration Form

Kids Clinic
Child's Name *

Prefix First Name Middle Name Last Name
DOB *

Month Day Year
Date Date Picker Icon

Address *

Unit/House
Street address
Suburb	State
Postcode	Country

Accompanied by: *

Mother Father Caregiver Other
If other than parents

First Name Last Name
Mother's Name *

First Name Last Name
Mother’s contact *

Mobile Number
Father’s Name

First Name Last Name
Father’s contact

Mobile Number
Emergency contact *

Mobile Number
Emergency Name *

First Name Last Name
List health professionals involved in the care of your child:

GP Paediatrician Speech therapist OT Psychologist Others
Reason for seeing the Paediatrician *

Learning Difficulties Developmental Disorder Speech Disorder Behavioural problems School Issues Allergy/Eczema/Asthma Constipation/Abdominal Pain Bedwetting Baby/Infant Check Sleep Disorder Growth issues Obesity Seizures/Abnormal Movements
Please indicate any previous diagnosis: *

Speech Delay Developmental Delay Asthma Autism Spectrum Disorder ADHD/ODD Learning Difficulties Anxiety
Child attends:

Childcare Preschool School Playgroup
Academic process:

Poor Below average Average Above average
Relevant (Related) family history:
Child’s parents: *

Married Divorced Separated Living together
Pregnancy History: Any significant or relevant complications?
Method of delivery:

Normal Caesarian
Term born:

Pre-term Term Post term Weeks of Gestation
Birth weight:
Kg
Developmental Milestones: Please tick all milestones your child has achieved

Walks Climbs Hops Skip Throws Kicks Catches Stacks blocks Threads beads, uses scissors Grips pencil Smile socially Points to items Sleeps Tantrums Pretend plays Share plays Speaks clearly Uses sentences Repeats Sounds Understand instructions Toilet trained Eats independently Can dress independently
Diet:

Eats well Fussy eater Unhealthy eater Vegeterian
Relevant medical history:
Is your child currently on medication?

Yes No
If “Yes” pleases state :
NAME, DOSE AND FREQUENCY OF MEDICATION
Review of symptoms: *

Hearing loss Visual concerns Loud snoring Impulsive Overactive Short attention span Frequent tantrums Sleeping concerns Aggressive behaviour Poor social skills Seizures Abnormal Movements/Tics
Are there any legal/family court proceedings in progress? *

Yes No
How will you be paying for the consultation? *

Private fees with Medicare rebate Private Insurance Support Organisation eg. FACS Compensation-personal injury claims
Consent:
I give permission for this information to be shared with other health care specialists and allied health services. I also consent for Dr Sam Nassar and all therapists which my child is receiving therapeutic services from at the Kids Clinic to consult and share information with third parties; which includes but is not limited to FACS, Centrelink and Medicare Australia.
Date

Month Day Year
Date Date Picker Icon
Name

First Name Last Name
Signature

Clear
Should be Empty:

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Administration Form