Pre-Appointment Questionnaire

*If the matter is urgent please have the referring doctor phone the practice on (02) 9634 8600.

Some children need to be seen more urgently than others, and the aim of this questionnaire is to determine how soon you child needs to be seen, and what tests your child might need on the day.

Please provide as much detail as possible in order to allow proper consideration of the urgency of the appointment. The more information you provide, the better.

If your child has eczema, please attach current photos of your child’s skin, to help with assessment of urgency.

The information you supply will allow proper allocation of time for your appointment, to avoid appointments running over the allocated time, and will minimise the time you spend in the waiting room before your appointment.

Please note that no appointments will be made without submitting this form.

If you wish to claim a Medicare rebate, a valid referral is required. Your child can still be assessed and managed without a referral, but you will not be able to make any claims from Medicare for the services provided. This is a Medicare requirement.

Full name of patient (first name, middle name, family name) (required)

Date of birth of patient

Name of Mother

Name of Father

Address

Suburb

State

Postcode

Contact email (required)

Contact phone number

Please explain your concerns, describing what happened to your child, and any reactions you have seen, including how long it took for the symptoms to appear. Please provide as much detail as possible in order to allow proper consideration of the urgency of the appointment. The more information you provide, the better.

What are other concerns you have about the patient’s health?

Has the patient had allergy tests before? If yes, please email a copy of the results to humpty@paediatrix.com.au
YesNo

Has the patient had blood tests before? If yes, please email a copy of the results to humpty@paediatrix.com.au
YesNo

What triggers have set off the problem? Please list:

Food

Environmental

Other

Is the patient eating a restricted diet or avoiding any particular foods?
Please detail the restrictions.

If you have any documents/files/photos you want to send us, please email them to humpty@paediatrix.com.au

Please remember to bring in your child’s medical records book (“Blue Book”), and all previous records of weight and height measurements.

You will receive an automated email in response to the successful receipt of your request for an appointment.
*Ps, if you do not hear from us within three business days please follow up with a phone call (02 9634 8600) or email humpty@paediatrix.com.au in case of technical difficulties.

IT IS VITAL THAT THE PRIMARY CAREGIVER BRINGS IN THE CHILD, AS OTHERS MAY NOT BE FAMILIAR WITH THE CHILD’S SYMPTOMS AND CARE. THE BEST PERSON TO COME TO THE APPOINTMENT IS USUALLY THE PERSON WHO PREPARES THE CHILD’S FOOD.

REMEMBER TO BRING YOUR BLUE BOOK TO THE APPOINTMENT AS THIS CONTAINS VALUABLE RECORDS OF GROWTH AND DEVELOPMENT.