Patient intake questionnaire

Filling out this form BEFORE your appointment helps your clinician prepare and helps your appointment run smoothly.

There are no right or wrong answers — please answer each question as best you can.

Allow approximately 30 minutes to complete the questionnaire.

Having your child with you may help you complete this form.

Patient First & Last Name *

Date of Birth *

Current age (years)

Name and relationship of person completing form *

Please list your 2 or 3 main concerns about your child *

Schooling concerns

Current school or daycare/kindergarten

Current year level if applicable

Favourite or most enjoyable aspect of school

Least favourite or most challenging aspect of school

Are you concerned about your child's learning or academic progress?

YesNo

Which learning areas are you mainly concerned about?

Reading Writing Maths Others

Click all that apply

Are you concerned about your child's learning or behaviour at school?

YesNo

Home

Does your child live between more than one household?

Who lives with the child?e.g. Relationship, first name, age, occupation, medical condition, medication

Who lives in household onee.g. Relationship, name, age, occupation, medical conditions, medication

Who lives in household two e.g. Relationship, first name, age, occupation, medical conditions, medication

Does your child have siblings who live outside the household?

Please list any siblings who do not live in the householde.g. Relationship, first name, age, known medical condition

Is there a family history of sudden unexplained death under the age of 40?

Please advise condition if known

Is there a history of arrythmia (abnormal heart rhythm) or congenital heart disease in the family?

Please advise of condition if known

Hobbies and interests

What does your child enjoy doing outside of school?

What are your child's strengths?

Sleep patterns

What is your child's usual bedtime?

Does your child have difficulites falling asleep at night time?

YesNo

How long does it typically take your child to fall asleep? (minutes)

Does your child snore at night?

Appetite and toiletting

Do you feel that your child is fussy with their intake?

Do you have concerns about your child's toiletting?

Social and emotional wellbeing

Do you have concerns about your child social skills?

Do you have concerns about your child's anxiety?

Do you have concerns about your child's mood?

Is your child between 7-18 years AND available to complete a questionnaire?

Pregnancy and early life

Were there any complications during the pregnancy? (please list)e.g. gestational diabetes, additional scans required, high blood pressure

Was there any alcohol, drugs or medications used during the pregnancy, even if accidental?

Please list alcohol, drugs or medications used during pregnancy.

Birth and delivery (click all that apply)

Did you have concerns about your child's early development? (first 18 months - click all that apply)

Poor or irregular sleep patternsHard to settle or was irritableDifficulties with establishing feedsMotor development (delay in sitting, crawling, walking)Speech development (delay in babbling, first words, communicating)Social skills (delays in smiling, laughing, eye contact)

Medical history

List any confirmed developmental diagnosese.g. ADHD, Autism, Global developmental delay

List any diagnosed medical conditions

List any surgical procedurese.g. adenoids and tonsils, grommets, hernia repair

List current medication

Allied health therapies and assessments

Additional information

Please click the button(s) below to download additional questionnaires for your child's teacher to complete

CLICK HERE

We appreciate the time and effort to complete these assessments!

If you have any report cards, assessment reports or medical information, please email to info@outreachqld.com.au

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