Mother's name *

First Name

Last Name

Father's name

First Name

Last Name

Were there any concerns during the pregnancy?

Yes

No

Where there any concerns at birth?

For example, resuscitation required or birth injury

Yes

No

Did your child have any problems as a newborn?

Yes

No

Is your child up to date with immunizations?

Yes

No

Did your child reach their milestones on time?

For example, crawling and walking, language development, social development, early learning

Yes

No

Has your child ever been involved with any of the following?

Paediatrician

Other medical specialist (eg ENT, Allergist)

Psychologist

Psychiatrist

Counselling

Child and Youth Mental Health

Speech Pathology

Occupational Therapy

Physiotherapy

Guidance Officer

Audiology (including hearing tests)

Has your child had any significant injury or accident?

Yes

No

Does your child have language difficulties?

Yes

No

Does you child have any social difficulties?

Yes

No

Does your child have any schooling issues?

Including social, behavioural or learning difficulties

Yes

No

Are there any custody issues?

Yes

No