Confidential New Patient Questionnaire
Please complete and submit this form at least three working days prior to your initial consultation with Jenny Edelstein. Any questions that do not apply to your child may be left blank. The questionnaire takes approximately 15 minutes to complete.
Date of birth *
Your answer
Address *
Your answer
Name of child *
Your answer
Personal details
Telephone number *
Your answer
Mobile number
Your answer
Email address *
Your answer
Family details
Names and ages of siblings
Your answer
Age of mother
Your answer
Do siblings have any significant developmental difficulties?
Your answer
Do siblings have any significant health problems?
Your answer
Profession of father
Your answer
Does father have any significant health problems?
Your answer
Age of father
Your answer
Does mother have any significant health problems?
Your answer
Name of father
Your answer
Name of mother
Your answer
What languages are spoken at home?
Your answer
Profession of mother
Your answer
Pregnancy and infancy
What percentile was your child for height and weight during the first two years?
Your answer
Type of birth
Has your child had surgery or any significant illnesses?
Your answer
Was it a difficult birth?
Please describe any complications.
Your answer
Was your child breastfed, and if so for how long?
Your answer
Did your child follow the official immunisation schedule?
If not please describe.
Your answer
At what age did your child begin to eat solid foods?
Your answer
Approximately how many times did your child take antibiotics during the first two years of life?
Your answer
Any ear infections in the first two years of life, and if so how many?
Your answer
Did your child have reflux as an baby?
How many weeks of gestation?
Your answer
Any complications during pregnancy?
Your answer
Did your child react to any immunizations?
Your answer
Weight and length of child at birth
Your answer
Developmental history
At what age did your child speak whole sentences?
Your answer
At what age was your child toilet trained?
Your answer
Please tick any of the following that you feel may apply to your child:
At what age did your child stand?
Your answer
What are your current concerns about your child's development?
Your answer
At what age did your child walk?
Your answer
Does your child have a diagnosis of a sensory, behavioural or developmental disorder?
If so, please provide details of who gave the diagnosis and when.
Your answer
At what age did your child crawl?
Your answer
At what point, if any, did you begin to have concerns regarding your child's development?
Your answer
Any comments on your answers above:
Your answer
At what age did your child speak his or her first words?
Your answer
Current health status
Does your child have any allergies?
If so please provide details.
Your answer
Does your child have any chronic illnesses such as asthma?
If so please provide details.
Your answer
Is your child currently taking any medication?
If so please provide details.
Your answer
What are your current concerns regarding your child's health?
Your answer
Your child's current height and weight
Your answer
How often does your child miss school or nursery due to illness?
Your answer
Does your child have any skin conditions such as eczema?
If so please provide details.
Your answer
Education
Does your child "fit in" socially?
Your answer
Does your child have a Statement or IEP?
If so please provide details.
Your answer
How would you describe his or her academic performance?
Your answer
Does your child receive Caudwell funding?
If so please provide Caudwell application number.
Your answer
What school or nursery does your child attend?
Your answer
Is your child receiving speech and language therapy, or any other therapies?
If so please provide details.
Your answer
Does your child receive any extra support at school?
If so please provide details.
Your answer
Eating habits
What foods does your child dislike, or refuse to eat?
Your answer
Does your child take any dietary supplements?
If so please provide details.
Your answer
What are your child's favorite foods?
Your answer
Does your child have any food allergies, to the best of your knowledge?
If so please provide details.
Your answer
Is your child currently on a special diet?
If so please provide details.
Your answer
Does your child crave certain foods?
If so please provide details.
Your answer
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