Online Intake Form
Please Note: We are a Paperless Practice utilising Electronic Health Records. This form will take approximately 5-10 minutes to complete. Several consent and policy forms within the intake will be required to be completed and signed. Please fill them out online at least 24 hours before our visit. All information is Confidential.
Please upload a recent photo of your child, preferably with the expected accompanied parents. The collection, use and storage of the photos is treated by Kids Clinic according to health service providers’ obligations under the Privacy Act 1988. By uploading the photo, you consent to the above terms and conditions.
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Child's Name
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Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
DOB
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/
Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
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Unit/House
Street address
Suburb
State
Postcode
Carer's Best Email
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example@example.com
Accompanied by:
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Mother
Father
Caregiver
Other (case worker, support person ....)
Other
Mother's Name
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First Name
Last Name
Mother's Contact
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Father’s Name
First Name
Last Name
Father's Contact
Emergency Name
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First Name
Last Name
Emergency Contact
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Referring Family Doctor(GP) or Specialist
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List health professionals involved in the care of your child:
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Family Doctor (GP)
Paediatrician
Speech therapist
OT
Psychologist
Others
Reason for seeing the Paediatrician
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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
General Check-up
Other
Please indicate any previous diagnosis:
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Speech Delay
Developmental Delay
Asthma
Autism Spectrum Disorder
ADHD/ODD
Learning Difficulties
Anxiety
None
Seizures
Allergy
Heart problems
Other
Child attends:
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Childcare
Preschool
School
Playgroup
None
Other
Please name the school
Academic process:
Poor
Below average
Average
Above average
Not Applicable
Other
Relevant (Related) family history:
Child’s parents:
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Married
Divorced
Separated
Living together
Siblings
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How many?
Pregnancy:
Smooth
Complicated
IVF
Method of Delivery
Normal
Vacuum
Forceps
Caesarean
Born at:
Pre-term
Term
Post-term
Birth weight:
Kg
Tick achieved milestones if your child is less than 6years of age:
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
If your child is taking medications please state :
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If "YES" NAME, DOSE AND FREQUENCY OF MEDICATION
Review of symptoms:
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Hearing loss
Visual concerns
Loud snoring
Impulsive
Overactive
Short attention span
Frequent tantrums
Sleeping concerns
Aggressive behaviour
Poor social skills
Seizures
Abnormal Movements/Tics
None
Other
Are there any legal/family court proceedings in progress?
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Yes
No
Appointment and Cancellation Terms and Conditions:
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I Do
Please mark the date of your appointment on your calendar. While we make every effort to remind our clients of appointments by email and phone two or more days prior to the appointment, it is the client's responsibility to maintain his or her schedule. Booking fee up to 100$ will incur when you make your appointment to secure it. Patients who do not attend their scheduled appointment and fail to give a minimum of 48 hours’ notice either by telephone or emailing info@kids-clinic.com.au will lose their booking fee. Extenuating circumstances will be reviewed on a case-by-case basis. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.
Consent to share information:
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I Do
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.
Communication Policy:
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I have read
We want to provide you with the best support possible on your child journey, and we endorse transparency and setting expectations up front so we are both on the same page with what we can provide outside of our visits together. This is our Communication Policy:- Questions are not answered on Text Message or Social Media Platforms for legal reasons- Email also poses security risks. If you decide to email us, please give us 1-5 business days to respond. Urgent Questions: call the Office at 02-8404 0567 and leave a message with our management team. We will call you back as soon as possible with an answer. For more Complex questions and new concerns: please book a 10-30 minutes follow-up visit so we can provide you with more appropriate support you deserve
Date
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Name
First Name
Last Name
Signature
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Submit
Should be Empty: