Getting to Know Your Child form page

Getting to Know Your Child Form

Please fill out this form and bring it to your appointment. We can help you fill it out at the appointment if needed.

Step 1 of 10 – Part 1: About you

10%

ABOUT YOU

You must be the child’s legal guardian to complete this form.

Your Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred days for an appointment

Monday

Tuesday

Wednesday

Thursday

Friday

ABOUT YOUR CHILD

Child's Name(Required)

First Last

Child's Age Range(Required)

0 – 18 months

18 months – 6 years

6 – 18 years

Date of birth(Required)

Things my baby is good at/ likes doing:

Things my child is good at/ likes doing:

What are your concerns about your child?

What are your concerns about your baby?

FAMILY

This section gives us information about other family members or carers who may be involved in your child’s care.

Parent or Carer's Name 1

First Last

Parent or Carer's Name 2

First Last

Who else lives at home? Please give the ages of all other children.

Are there any guardianship, custody or access arrangements involving the child?

Yes

If yes, please provide additional details.

Has your family experienced any stressful events?

(Death in family, separation, family violence)

Yes

If yes, please provide additional details.

Has anyone in your family had speech, language or learning problems?

Yes

If yes, please provide additional details.

What languages do you speak at home?

OTHER IMPORTANT PEOPLE AND COMMUNITY SUPPORTS

This section gives us information about other important people and professionals who may be involved in your child’s care.

GP name and practice

Name of childcare

Name of childcare/ kindergarten

Do you see a Paediatrician/Specialist?

Yes

If yes, please provide their name and details here

Does your child see a paediatrician, other professionals?

Yes

If yes, please provide their name and details here

Name of school

Year level

Does your child participate in activities outside of school?

Yes

If yes, please provide additional details.

EARLY DEVELOPMENT

This section gives us information about your child’s early health and development.

Were there difficulties with your pregnancy or your child's birth?

If yes, please provide details

Was your child delayed in any areas growing up?

E.g. walking, talking eating. If yes, please provide details

Do you have any concerns about the following in your child? if yes to any, please provide details for each.

Were there any difficulties with your pregnancy or your child’s birth?

Yes

If yes, please provide additional details.

What was your child's birth weight?

What age did your child first roll?

What age did your child first sit?

What age did your child first crawl?

What age did your child first walk?

What age did your child first use words?

What age did your child first start putting words together?

Does your baby look at your and follow your movements?

Yes

Does your baby respond to familiar people and voices?

Yes

Does your baby hold onto toys?

Yes

Does your baby enjoy tummy time?

For how long, how many times each day?

Does your child have any pain?

If yes, please provide more details

HEALTH

This section gives us information about your child’s overall health and development.

Were there difficulties with your pregnancy or your baby's birth?

If yes, please provide details

What was your baby's birth weight?

Has your child had any illnesses, accidents or operations?

Yes

If yes, please provide additional details.

Has your baby had any illnesses, accidents or operations?

Yes

If yes, please provide additional details.

Does your child have any allergies?

Yes

If yes, please provide additional details.

Does your baby have any allergies?

Yes

If yes, please provide additional details.

Does your child get ear infections or frequent colds?

Yes

If yes, please provide additional details.

Does your child take any medications?

Yes

If yes, please list.

Does your baby take any medications?

Yes

If yes, please list.

Has your child's been hearing tested since birth?

Yes

If yes, please provide; where, when and result;

Are there any concerns about hearing or vision?

Yes

If yes, please provide details

Hearing tests results:

Where, when and result:

Does your child go to the dentist?

Yes

EATING AND NUTRITION

This section gives us information about your child’s nutrition and eating habits

Do you have any concerns about your baby's weight or growth?

Yes

If yes, please provide additional details.

Is your baby a good feeder?

Breast, bottle, solids

Yes

Please provide additional details.

Does your baby feed themselves with finger food or a spoon?

Yes

Please provide additional details.

Do you have any concerns about your child's weight or growth?

Yes

If yes, please provide additional details.

Does your child eat the same food as the rest of the family?

Yes

If not, please provide additional details. how is this different?

Does your child feed themselves with a fork/ spoon/ knife?

Yes

Please provide additional details.

SPEECH AND LANGUAGE DEVELOPMENT

This section is not applicable to this age range. Go to the next section.

SPEECH AND LANGUAGE DEVELOPMENT

Does your baby make sounds often? Does your baby copy sounds or words that you make?

If yes, please provide details.

Does your baby say any words?

E.g. “Dadda” for Dad, “Mumma” for Mum

Does your baby look at your when you say their name?

Does your baby give you a toy/ food when you ask for it?

Does your baby clap, wave or point?

Does your child understand/ follow instructions (with/ without pointing?)

Yes

Please provide details:

How does your child communicate (e.g. pointing, noises, using one word, using sentences)??

Is your child's speech easy to understand?

Yes

Please provide details:

ATTENTION AND LISTENING

Tell us about your child's attention and listening skills

E.g. sitting still, finishing activities

PLAY, SOCIAL SKILLS AND EVERYDAY SKILLS

This section is not applicable to this age range. Go to the next section.

PLAY, SOCIAL SKILLS AND EVERYDAY SKILLS

Do you have any concerns about your baby's behaviour?

Does your baby settle easily, does your baby happily go to other people? Please provide details

Tell us about your baby's sleep habits

E.g. times of sleep, settling to sleep, waking through the night, snoring

Does your baby have any strong or unsual reactions to noise, taste, touch or movement?

If yeas, please provide details

Does your child like messy play?

E.g. play-dough, pasting, dirt/ mud?

Yes

What does your child like to play with?

How well does your child play with others?

Does your child like to draw?

Yes

Does your child use scissors?

Yes

How independent is your child?

E.g. separates easily from parents, tries new things?

Does your baby like to play games like peek-a-boo?

Please provide details

What does your baby like to play with?

Does your baby put a toy phone to their ear or push a car along?

Do you have any concerns about the child's behaviour/ emotions

If yes, please explain

Does your child play safely without supervision?

How independent is your child?

E.g. separates easily from parents, tries new things?

Does your child have any strong or unusual reactions to noise, taste, touch or movement?

If yes, please explain

Does your child suck their thumb?

Yes

Does your child dress themself?

Yes

Tell us about your child's sleeping habits

E.g. bedtime, getting to sleep/ waking during the night, snoring)

Is your child toilet trained?

Yes

Does your child use a dummy?

Yes

MOTOR SKILLS

This section is not applicable to this age range. Go to the next section.

MOTOR SKILLS

Do you have any concerns about your baby's posture?

Head, spine, arms, legs and feet? If yes. please provide details.

Do your baby roll:

Please tick all that apply

Back to tummy?

Tummy to back?

Over both right and left sides?

Does your baby move on tummy to get to toys?

E.g. pivot to the side, get onto hands and knees?

Does your baby like to stand with your support?

Does your baby sit with support?

Does your baby sit alone when placed in a sitting position?

Does your baby move independently from:

Please check all that apply

Lying to sitting?

Lying to crawling position?

Crawling to standing with support?

Squatting to standing alone?

Does your baby:

Please check all that apply

Commando crawl or crawl on all fours?

Walk around holding onto furniture or your hands?

Walk around pushing a trolley?

Walk independently?

Do you have any concerns about your child's walking?

E.g. toe walker, pigeon toed, frequent tripping/ falling over?

Do you have any concerns about your child's other motor skills?

E.g. running, jumping, hopping, climbing, call skills, bike riding?

Do you have any concerns about your child's posture?

Head, spine arms, legs and feet

Yes

If yes, please provide additional details.

Does your child often complain of pain?

Yes

If yes, please provide additional details.

Do you have any concerns about your child's balance and coordination skills

Yes

If yes, please provide additional details.

Other Comments

Do you have any other comments or things you want us to know?

Name

This field is for validation purposes and should be left unchanged.

Your Community Health

Getting to Know Your Child form page