Parent Questionnaire - All About Kids

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:



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:



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


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


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



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



Clinic:

Clinic:

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[email protected] www.allaboutkids.com.auShop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009


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



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:



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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Documents

Parent Questionnaire - All About Kids