Child Information Form

General Patient Information
Please complete the following questions about yourself
Parent/Guardian Full Name*
PrefixFirst NameLast Name
Preferred Name
Parent/Guardian Date of Birth*
YearMonthDay
Date
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Medicare Number
Medicare NumberIRN
Email*
example@example.com
Relationship Status
Number of Children
Mobile Phone*
Home Phone
Phone Number
Preferred method of contact/confirmation*
How did you hear about us?*
Please answer the following questions about your child
Child's Full Name*
First NameLast Name
Child Birth Date*
YearMonthDay
Date
Medicare Number
Medicare NumberIRN
Medical History
If he/she is taking prescribed medication, please list them here:
How would you describe your child's physical health at present?
Very GoodGoodFairUnsatisfactoryPoor
Please describe your child's sleeping habits:*
NormalSleeping too littleSleeping too muchDisturbing dreamsPoor sleep quality
Describe your child's eating habits*
NormalEating too littleEating too muchBinge eatingRestricting
In the last year, has your child experienced any significant life changes or stressful situations?

Has your child ever experienced the following?*

	Yes	No
Extreme Depression
Wild Mood Swings
Rapid Speech
Extreme Anxiety
Panic Attacks
Difficulty Breathing
Drug Abuse
Phobias
Sleep Disturbances
Hallucinations
Unexplained Loss of Time
Unexplained Memory Loss
Frequent Body Complaints
Eating Disorder
Body Image Problems
Repetitive Thoughts (Obsessions)
Repetitive Behaviours (Hand-washing, Checking)
Homicidal Thoughts
Suicide Attempt

General Patient Information