PANDAS Baseline Assessment Form
Please complete this form for your first appointment
Email *
Children's e-Hospital Identity Number *
Parents Name *
Child's Name *
Child's Date of Birth *
MM
/
DD
/
YYYY
Home Address *
Recent weight (Kg) *
GP Name & Address *
Briefly tell us what your child's problem is? *
Please give as much detail about your child's problem. If your child has Obsessive Compulsive Behaviour or Tics please fill in the additional assessment forms *
Which of the following investigations have you had done? *
Required
Please give any results from investigation *
Which of the following symptoms does your child have? *
Required
Has your child been diagnosed with Autism or ADHD? *
Tell us about your child's past medical problems
Which of the following medicines has your child received within the past 3 months? *
Required
What medicines is your child currently receiving? *
What Drug Allergies does your child have? *
On a scale of 1-10, How much school has your child missed?
Fully attended school
Missed all school
Clear selection
Parents age & Occupation *
Please list any siblings & their ages *
Please list any medical conditions that run in the family? *
Submit
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