Getting to Know Your Child form page Getting to Know Your Child form page Getting to Know Your Child Form Please fill out this form and bring it to your appointment. We can help you fill it out at the appointment if needed. Step 1 of 10 – Part 1: About you 10% ABOUT YOUYou must be the child’s legal guardian to complete this form.Your Name(Required) First Last Email(Required) Phone(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred days for an appointment Monday Tuesday Wednesday Thursday Friday Select All ABOUT YOUR CHILDChild's Name(Required) First Last Child's Age Range(Required) 0 – 18 months 18 months – 6 years 6 – 18 years Date of birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Things my baby is good at/ likes doing:Things my child is good at/ likes doing:What are your concerns about your child?What are your concerns about your baby? FAMILYThis section gives us information about other family members or carers who may be involved in your child’s care.Parent or Carer's Name 1 First Last Parent or Carer's Name 2 First Last Who else lives at home? Please give the ages of all other children.Are there any guardianship, custody or access arrangements involving the child? Yes No If yes, please provide additional details.Has your family experienced any stressful events?(Death in family, separation, family violence) Yes No If yes, please provide additional details.Has anyone in your family had speech, language or learning problems? Yes No If yes, please provide additional details.What languages do you speak at home? OTHER IMPORTANT PEOPLE AND COMMUNITY SUPPORTSThis section gives us information about other important people and professionals who may be involved in your child’s care.GP name and practice Name of childcare Name of childcare/ kindergarten Do you see a Paediatrician/Specialist? Yes No If yes, please provide their name and details hereDoes your child see a paediatrician, other professionals? Yes No If yes, please provide their name and details hereName of school Year level Does your child participate in activities outside of school? Yes No If yes, please provide additional details. EARLY DEVELOPMENTThis section gives us information about your child’s early health and development.Were there difficulties with your pregnancy or your child's birth?If yes, please provide detailsWas your child delayed in any areas growing up?E.g. walking, talking eating. If yes, please provide detailsDo you have any concerns about the following in your child? if yes to any, please provide details for each.Eating habits/ weight/ growth | communication skills | using hands for everyday activities (e.g. handwriting, cutlery) | learning at school | social interaction and friendships | participation in physical activity (e.g. balance/ coordination, tripping, tip-toeing) | behaviour, emotions or self-esteem | sleeping habits Were there any difficulties with your pregnancy or your child’s birth? Yes No If yes, please provide additional details.What was your child's birth weight? What age did your child first roll? What age did your child first sit? What age did your child first crawl? What age did your child first walk? What age did your child first use words? What age did your child first start putting words together? Does your baby look at your and follow your movements? Yes No Does your baby respond to familiar people and voices? Yes No Does your baby hold onto toys? Yes No Does your baby enjoy tummy time?For how long, how many times each day? Does your child have any pain?If yes, please provide more details HEALTHThis section gives us information about your child’s overall health and development.Were there difficulties with your pregnancy or your baby's birth?If yes, please provide detailsWhat was your baby's birth weight? Has your child had any illnesses, accidents or operations? Yes No If yes, please provide additional details.Has your baby had any illnesses, accidents or operations? Yes No If yes, please provide additional details.Does your child have any allergies? Yes No If yes, please provide additional details.Does your baby have any allergies? Yes No If yes, please provide additional details.Does your child get ear infections or frequent colds? Yes No If yes, please provide additional details.Does your child take any medications? Yes No If yes, please list.Does your baby take any medications? Yes No If yes, please list.Has your child's been hearing tested since birth? Yes No If yes, please provide; where, when and result;Are there any concerns about hearing or vision? Yes No If yes, please provide detailsHearing tests results:Where, when and result: Does your child go to the dentist? Yes No EATING AND NUTRITIONThis section gives us information about your child’s nutrition and eating habitsDo you have any concerns about your baby's weight or growth? Yes No If yes, please provide additional details.Is your baby a good feeder?Breast, bottle, solids Yes No Please provide additional details.Does your baby feed themselves with finger food or a spoon? Yes No Please provide additional details.Do you have any concerns about your child's weight or growth? Yes No If yes, please provide additional details.Does your child eat the same food as the rest of the family? Yes No If not, please provide additional details. how is this different?Does your child feed themselves with a fork/ spoon/ knife? Yes No Please provide additional details. SPEECH AND LANGUAGE DEVELOPMENTThis section is not applicable to this age range. Go to the next section.SPEECH AND LANGUAGE DEVELOPMENTDoes your baby make sounds often? Does your baby copy sounds or words that you make?If yes, please provide details.Does your baby say any words?E.g. “Dadda” for Dad, “Mumma” for Mum Does your baby look at your when you say their name? Does your baby give you a toy/ food when you ask for it? Does your baby clap, wave or point? Does your child understand/ follow instructions (with/ without pointing?) Yes No Please provide details:How does your child communicate (e.g. pointing, noises, using one word, using sentences)??Is your child's speech easy to understand? Yes No Please provide details:ATTENTION AND LISTENINGTell us about your child's attention and listening skillsE.g. sitting still, finishing activities PLAY, SOCIAL SKILLS AND EVERYDAY SKILLSThis section is not applicable to this age range. Go to the next section.PLAY, SOCIAL SKILLS AND EVERYDAY SKILLSDo you have any concerns about your baby's behaviour?Does your baby settle easily, does your baby happily go to other people? Please provide detailsTell us about your baby's sleep habitsE.g. times of sleep, settling to sleep, waking through the night, snoringDoes your baby have any strong or unsual reactions to noise, taste, touch or movement?If yeas, please provide detailsDoes your child like messy play?E.g. play-dough, pasting, dirt/ mud? Yes No What does your child like to play with? How well does your child play with others? Does your child like to draw? Yes No Does your child use scissors? Yes No How independent is your child?E.g. separates easily from parents, tries new things? Does your baby like to play games like peek-a-boo?Please provide details What does your baby like to play with? Does your baby put a toy phone to their ear or push a car along? Do you have any concerns about the child's behaviour/ emotionsIf yes, please explain Does your child play safely without supervision? How independent is your child?E.g. separates easily from parents, tries new things? Does your child have any strong or unusual reactions to noise, taste, touch or movement?If yes, please explain Does your child suck their thumb? Yes No Does your child dress themself? Yes No Tell us about your child's sleeping habitsE.g. bedtime, getting to sleep/ waking during the night, snoring)Is your child toilet trained? Yes No Does your child use a dummy? Yes No MOTOR SKILLSThis section is not applicable to this age range. Go to the next section.MOTOR SKILLSDo you have any concerns about your baby's posture?Head, spine, arms, legs and feet? If yes. please provide details. Do your baby roll:Please tick all that apply Back to tummy? Tummy to back? Over both right and left sides? Does your baby move on tummy to get to toys?E.g. pivot to the side, get onto hands and knees? Does your baby like to stand with your support? Does your baby sit with support? Does your baby sit alone when placed in a sitting position? Does your baby move independently from:Please check all that apply Lying to sitting? Lying to crawling position? Crawling to standing with support? Squatting to standing alone? Does your baby:Please check all that apply Commando crawl or crawl on all fours? Walk around holding onto furniture or your hands? Walk around pushing a trolley? Walk independently? Do you have any concerns about your child's walking?E.g. toe walker, pigeon toed, frequent tripping/ falling over? Do you have any concerns about your child's other motor skills?E.g. running, jumping, hopping, climbing, call skills, bike riding? Do you have any concerns about your child's posture?Head, spine arms, legs and feet Yes No If yes, please provide additional details.Does your child often complain of pain? Yes No If yes, please provide additional details.Do you have any concerns about your child's balance and coordination skills Yes No If yes, please provide additional details. Other CommentsDo you have any other comments or things you want us to know?NameThis field is for validation purposes and should be left unchanged.