Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Pre-clinic questionnaire
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au
Child’s full name: Click here to enter text.
What are your concerns for your child?
Click here to enter text.
When did you first notice the problem?
Click here to enter text.
Has a diagnosis been made for your child? Please select.
What are your child’s strong points / good qualities?
Click here to enter text.
What are you expecting from the clinic?
Click here to enter text.
Medications:
Dosage / frequency:
Click here to enter text.
Click here to enter text.
Effectiveness of medications:
Click here to enter text.
Medication side-effects:
Click here to enter text.
Allergies:
Click here to enter text.
Are your child’s immunisations up to date (provide details if applicable)?
Click here to enter text.
Family history of Medical / Learning / Mental health issues:
Click here to enter text.
MILESTONES
Sit alone: Provide approximate age.
Crawled: Provide approximate age.
Stand: Provide approximate age.
First steps / walk (independently without holding on): Provide approximate age.
Run: Provide approximate age.
Jump: Provide approximate age.
Pedal tricycle: Provide approximate age.
Speech:
Babble: Provide approximate age.
First word: Provide approximate age.
Page 1 of 6
Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Pre-clinic questionnaire
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au
Two word phrase: Provide approximate age.
Toilet training
Indicates wee / poo: Select. When: Provide approximate age.
Bladder control: Select.
When: Click here to enter text.
Bowel control: Select.
When: Click here to enter text.
Other medical issues? Please select.
Any sleep issues? Please select.
Time sleep: Click here to enter text.
Time wake: Click here to enter text.
Snoring (please select): Choose an item.
Any dietary issues (provide details)? Please select.
Previous hearing test: Please select.
Previous vision test: Please select.
Does your child display any of the following (select those that apply)
☐ normal use of eye contact
☐ uses his/her index finger to point at things
☐ plays with toys imaginatively
☐ relates and plays with other children of similar age
☐ shows affection towards other people
☐ seeks comfort when hurt
☐ usually able to read emotions / thoughts of other children during play or
interactions
Does your child display any of the following (select those that apply)
☐ have unusual routines
☐ lines up toys
☐ fixated or repetitive interests / obsessions
☐ repetitive use of words / singing / sounds
☐ overly sensitive to sound / light / smells / taste
☐ mouth objects or puts things into his/her mouth often
☐ touching or feeling different surfaces
☐ overly preoccupied with looking at himself / herself in the mirror
☐ aggressive or destructive
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Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Pre-clinic questionnaire
BIRTH HISTORY
Conception: Please select.
Complications or issues in pregnancy:
Please select.
Medications in pregnancy:
Please select.
Cigarette use / smoking (how much, when stopped):
Please select.
Alcohol use (how much, when stopped):
Please select.
Gestation at birth (how many weeks): Click here to enter text.
Method of delivery (please select):
☐ Normal vaginal
☐ Caesarean - emergency
☐ Vacuum
☐ Caesarean - elective
☐ Forceps
Apgar scores:
At 1 minute: Please select.
At 5 minutes: Please select.
Birth weight: Click here to enter text. Length: Click here to enter text.
Head circumference: Click here to enter text.
Infant feeding (please select):
☐ Breast (until: Click here to enter a date.)
☐ Expressed Breast Milk
☐ Bottle
☐ Formula
☐ Mixed
Feeding difficulties:
Choose an item.
Transitioning to solids
Age: Click here to enter text.
Difficulties? Choose an item.
Page 3 of 6
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au
Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au
Pre-clinic questionnaire
Please rate the following for your child with regards to his/her behaviours over the
last 6 months, in comparison to other children of the same age:
0=Never
1=Sometimes/occasionally
2=Often
3=Very often/always
Does not pay attention to detail / makes careless mistakes
Select
Has difficulty keeping attention to what needs to be done
Select
Select
Does not seem to listen when spoken to directly
Does not follow through when given directions and fails to finish activities
Select
Select
Has difficulty organising tasks and activities
Avoids / dislikes / do not want to start tasks that require ongoing mental effort
Select
Select
Loses things necessary for tasks or activities
Select
Is easily distracted by noises or other stimuli
Select
Is forgetful in daily activities
Select
Fidgets with hands or feet or squirms in seat
Select
Leaves seat when remaining seated is expected
Runs about or climbs too much when remaining seated is expected
Select
Select
Has difficulty playing or beginning quiet play activities
Select
Is “on the go” or often acts as if “driven by a motor”
Select
Talks too much
Blurts out answers before questions have been completed
Select
Select
Has difficulty waiting his or her turn
Interrupts or intrudes in on others’ conversations and/or activities
Select
Select
Argues with adults
Select
Loses temper
Actively defies or refuses to go along with adults’ requests or rules
Select
Select
Deliberately annoys people
Select
Blames others for his or her mistakes or misbehaviours
Select
Is touchy or easily annoyed by others
Select
Is angry or resentful
Select
Is spiteful and wants to get even
Please rate your child’s performance below:
1=Excellent 2=Above average
3=Average
4=Below average
5=Problematic
Overall school performance
Select.
Reading
Select.
Writing
Select.
Mathematics
Select.
Relationship with parents
Select.
Relationship with siblings
Select.
Relationship with peers
Select.
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Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Pre-clinic questionnaire
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au
Teacher Questionnaire
Dear Sir / Madam,
Please complete this questionnaire and return it to:
Dr Alaric Koh
skc.chatswood@gmail.com (preferred)
Suite 7, 56 Neridah Street,
Chatswood NSW 2067
Child’s full name: Click here to enter text.
Teacher’s name: Click here to enter text.
Class: Click here to enter text.
How long have you known the child: Click here to enter text.
Please rate his / her behaviour over the last 3 months.
0=Never 1=Sometimes/occasionally 2=Often 3=Very often/always
Has difficulty sustaining attention to tasks or activities
Select.
Select.
Does not seem to listen when spoken to directly
Select.
Does not follow through on instructions and fails to finish schoolwork
Select.
Has difficulty organising tasks and activities
Select.
Avoids / dislikes / does not want to start tasks that require ongoing mental effort
Select.
Loses things necessary for tasks or activities
Select.
Is easily distracted by extraneous stimuli
Select.
Is forgetful in daily activities
Select.
Fidgets with hands or feet or squirms in seat
Select.
Leaves seat in classroom / other situations where remaining seated is expected
Select.
Runs about / climbs excessively where remaining seated is expected
Select.
Has difficulty playing or engaging in leisure activities quietly
Select.
Is “on the go” or often acts as if “driven by a motor”
Select.
Talks excessively
Select.
Blurts out answers before questions have been completed
Select.
Has difficulty waiting in line
Select.
Interrupts or intrudes on others (eg. butts into conversations / games)
Select.
Loses temper
Select.
Actively defies or refuses to comply with adult’s requests or rules
Select.
Is angry or resentful
Select.
Is spiteful or vindictive
Select.
Bullies, threatens or intimidates others
Select.
Initiates physical fights
Select.
Lies to obtain goods for favours or to avoid obligations (eg. “cons” others)
Select.
Is physically cruel to people
Select.
Has stolen items of non-trivial value
Select.
Deliberately destroys others’ property
Select.
Fails to give attention to details or makes careless mistakes in schoolwork
Page 5 of 6
Suite 7, 56 Neridah Street
Chatswood NSW 2067
Dr Alaric Koh MBBS PRACP
Developmental and Behavioural Paediatrician
Pre-clinic questionnaire
Page 6 of 6
Ph: 9412 2822
Fax: 9412 1000
Email: skc.chatswood@gmail.com
www.sydneykidsclinic.com.au