Parent Questionnaire - Dr Leila Masson · Parent Questionnaire Please fill out this form on a...
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Child's Name: Date: Date Of Birth: Parents' Names: Parents' Occupation: Parent Questionnaire Please fill out this form on a computer if possible, otherwise print out and fill in by pen. If you feel comfortable emailing this information send it to [email protected]. Otherwise bring it on a memory stick or print it out. Age: Siblings: Ages: Concerns (for siblings): Yes No Smoker(s) in household: Main issues to be addressed about your child: When did you first notice the problem? Current Medications/supplements: Other problems to be addressed: Your child's strengths: Address: Phone number: Email address: Child's Medicare number and position on the card: Date of expiry of the Medicare card: Medicare account holder's name: Date of birth of Medicare account holder:
Transcript of Parent Questionnaire - Dr Leila Masson · Parent Questionnaire Please fill out this form on a...
Child's Name:
Date:
Date Of Birth:
Parents' Names:
Parents' Occupation:
Parent Questionnaire Please fill out this form on a computer if possible, otherwise print out and fill in by pen. If you feel comfortable emailing this information send it to [email protected]. Otherwise bring it on a memory stick or print it out.
Age:
Siblings: Ages:
Concerns (for siblings):
Yes NoSmoker(s) in household:
Main issues to be addressed about your child:
When did you first notice the problem?
Current Medications/supplements:
Other problems to be addressed:
Your child's strengths:
Address:
Phone number: Email address:
Child's Medicare number and position on the card:
Date of expiry of the Medicare card:
Medicare account holder's name:
Date of birth of Medicare account holder:
Pregnancy for Child Concerned
Stress:
Illness:
Maternal Age at Delivery:
Number of amalgams (silver fillings in teeth) present when pregnant:
Dental work during pregnancy:
Diet:
Fish consumption (meals per week):
Supplements during pregnancy:
Medications (including antibiotics):
Vaccines received: Rhogam
Toxic exposure - at home or work:
Any complications:
Birth
Alcohol consumption:
Gestation (weeks):
Normal vaginal Assisted Delivery Caesarian, reason:
Medications during labour:
Complications/resuscitation required:
Apgars if known:
Renovation Lead paint removed
Newborn PeriodUncomplicated Jaundice Required phototherapy
Other complications:
Medications given (e.g. antibiotics):
Days spent in special care nursery: / NICU:
Poor latch Insufficient milk supplyBreastfeeding problems:
Other:
How long breastfed for: exclusive (months): Total time:
Tongue tie Mastitis
First Year Medical ProblemsColic Reflux Eczema/dry skin Ear infections Recurrent nappy rash
Diarrhoea / constipation:
Allergies:
Did you associate any of the above with your diet if breastfeeding?
Recurrent infections: Age at first infection:
Courses of antibiotics first year: Hospital admissions:
Interactive and sociable Played peek-a-boo Smiled Developing normally
In his/her own world - not interacting with parents
Any other information?
1-5 Years Medical Problems
Allergies: Asthma:
Eczema:
Other skin problems:
Food intolerance/sensitivities:
Constipation: Diarrhoea:
Abdominal pain:Alternating diarrhoea and constipation
Rolled over at sat up at crawled at walked at
Seizures:
Hospital admissions:
Speech problems:
Does child lean over furniture to increase pressure on abdomen?
Night wakening with pain?
Other problems:
Courses of antibiotics:Recurrent infections:
Behaviour problems:
Sleep problems?
Separation anxiety? Developmental problems?
School Age Medical ProblemsAs Above
New symptoms:
Hospital admissions:
Total courses of antibiotics received to date:
Rode 2-wheel bicycle:
Developmental HistoryPlease list the age when the following skills were mustered and any problems associated with these skills:
First words:
Phrases or sentences:
Walking:
Jumping:
Running:
Toilet trained faeces
Walking up/down steps without help:
Toilet trained urine
Put on own clothing:
Learned to pedal:
Education History - any help required?
Day care:
Kindergarten:
School year:
Teacher aide:
Name of school:
Therapies: ABA x hrs/wk RDI Speech Therapy Physiotherapy
OT Braingym Cranial Osteopath Chiropractor
List any allergies, major illnesses, genetic diseases or problems for each of the following family members (include psych and learning issues)
Mother:
Father:
Siblings:
Maternal Grandparents:
Paternal Grandparents:
Others:
Family History
ImmunizationsUp to Date Incomplete
If incomplete, please list the vaccines received:
Reason for incomplete vaccines:
Reactions: Fever Irritability Prolonged crying Seizures
Onset of recurrent infections post vaccine:
Dietary / Nutritional History
Foods - begun at what age? First foods:
If yes, begun at what age?Cow's milk:
Known allergies to food (please list):
Suspected sensitivities to foods (please list):
Food cravings (please list):
NoYes
Foods Daily 3-5 x per week 1-3x per week Never Before any changes
Foods my child eats: (please tick appropriate boxes)
Cookies
Confectionary
Sweet food
Caffeine (fizzy, tea)
Milk: whole
Milk: trim
Cheese
Ice cream
Salty food
Meat
Pasta
Bread - white
Bread - whole wheat
Mostly baby
Mostly carbohydrates (bread, pasta, etc.)
Mostly dairy (milk, cheese, etc.)
Mostly meat
Mostly vegetarian (vegetables, fruits, grains, etc.)
Other (please describe):
Please tick the most appropriate description of your child's diet:
picky eatermy child has a good appetite eats a variety of foods often hungry never hungry
Breastfed until what age? Formula from what age?
Other:
Please list the foods and drink normally consumed by your child for 3 typical days:
Breakfast:
Morning snack:
Lunch:
Afternoon snack:
Dinner:
Day 1:
Dietary / Nutritional History (continued)
Breakfast:
Morning snack:
Lunch:
Afternoon snack:
Dinner:
Other:
Day 3:
Breakfast:
Morning snack:
Lunch:
Afternoon snack:
Dinner:
Other:
Day 2:
Please describe your child's bowel motions:
Special diets tried?
formed
painful
Frequency:
hard pellets pasty mushy runny undigested food mucus blood
flatulence
Colour: Size: Smell:
Other information:
Social History
Who lives in your home with your child?
Pets in the house:
Caregivers beside parents:
List the people important in your child's life:
Recent travel:
Is your child interested in any sports, music or other activities? Please describe:
Child's response to these changes:
Recent changes, losses, births, deaths, divorces, remarriage or moves:
How do you as a parent deal with these emotions in your child?
What makes your child happy?
How does your child interact with other children?
How does your child interact with adults?
What makes your child sad?
What makes your child angry?
What makes your child stressed?
How do you describe your parenting style
Parenting programmes attended?
Psychological therapies tried?
Current State of Health
Sleep:
Chatty/giggly in early AM
Gut: Abdominal pain Diarrhoea Constipation
Pain: Headaches Joint pain Muscle aches Other:
High pain threshold (does not cry easily when hurt)
General Mood: Happy Sad/depressed Agitated Other:Anxious
Behaviour: cooperative oppositional kind aggressive
Wakes up during night, what time?
Energy: ready to jump out of bed in the morning needs a long time to get upstill tired in the morning
active and energetic during the day keeps up with peers tires easily needs rest after play
empathic
Was there any other event or illness that you or others think brought on your child's symptoms? (please be specific)
How would you rate the overall health of your child? Do they fight off infections quickly?
Any other relevant information you feel is important:
Sensory issues: dislikes being touched dislikes labels in clothes
dislikes brushing hair
dislikes scratchy clothes
dislikes brushing teeth dislikes washing hair
other sensory issues:
dislikes noise dislikes bright lights
How many naps?
Daily time spent on screens: Daily time spent playing outdoors
Bloating Fatulence
Takes how long to fall asleep? Asleep by? Awake by?
Symptom RecordPlease tick symptoms your child has and give details if necessary:
Symptom Past Present Details
Possible clues to zinc deficiency:
Recurrent Infection
Slow recovery from infection
Poor wound healing
Stretch marks
Irritability
White spots on nails
Poor memory
Mental lethargy
Poor taste/appetite
Acne
Possible clues to high copper:
Symptom Past Present Details
Tantrums
Angry outbursts
Hyperactivity
Agitation
Violent behaviour
Jekyll and Hyde behaviour
Low mood
Learning problems
Possible clues to deficiency of zinc and B6
Anxiety / Tension
Fears
Mood swings
Light/sound sensitivity
Dislikes labels/scratchy clothing
Aversion to breakfast
Stress intolerance
Symptom Past Present Details
ADHD Behaviour Symptoms
Tantrums
Inattention
Impulsivity
Fidgety
Poor organisation
Distractible
Poor short-term memory
Oppositional
Defiance
Fearlessness
Symptom Past Present Details
Red cheeks
Red ring around anus
Itchy anus
Silly giggly behaviour
Fungal type skin rashes
Craving carbs/sugar
Clues to Yeast Overgrowth
Symptom Past Present Details
bumpy skin on upper arms
dry skin/scalp
learning problems
low mood
Clues to low omega 3 essential fatty acids
Symptom Past Present Details
muscle cramps/tics
constipation
sleep problems
anxiety
Clues to low magnesium
Symptom Past Present Details
ASD Symptoms
Stimming
Head banging
Self abuse
Poor eye contact
Toe walking
Delayed comprehension
Speech delay
Low muscle tone
Sideways glance
Poor socialization
Lack of imaginative play
Inappropriate play
Repetitive behaviour
Transition problems
Rigid with routines
Echolalia: repeats words
Scripting: repeats books, TV shows
Obsessions
Compulsions
Prefers to be alone
Avoids physical contact
Textural sensitivities
Smell sensitivities
Pica: eats dirt/soil
Poor fine motor skills
Poor gross motor skills
Symptom Record (continued)
