child medical health form (0 - 12 months)

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MEDICAL HISTORY FORM - CHILD (0 - 2 YEARS)

Please ensure you have completed an Allied Health Patient Contact Details Form prior to completing this Medical History Form for your child.

Has your child had any other treatment for the current problems?
Pregnacy Information
YesNo
Did you smoke during your pregnancy?
Did you drink alcohol during your pregnancy?
Did you take any medication during your pregnancy?
Did any abdominal injury occur?
Did you experience any fever and/or rash?
Were you diagnosed with Gestational Diabetes?
Did you experience morning sickness?
Did you experience any vaginal bleeding?
Were you diagnosed withToxemia, Eclampsia, Preeclampsia?
Did you have any surgeries while pregnant?
Did you have high blood pressure?
Were you told you had Rh incompatibility?
At Birth:
YesNo
Did your baby have bruises?
Did your baby have birthmarks?
Did your baby have any breathing problems?
Did your baby cry quickly?
Was the cord wrapped around your baby's neck?
Did your baby have jaundice?
Was your baby placed in an incubator/or in ICU?
Did your baby have seizures or convulsions?
Was your baby placed on a breathing machine?
Was fluid stained with your baby's meconium (bowel movement)?
Was your baby considered to be limp?
Was your baby considered to be stiff?
Did your baby have feeding or sucking problems?
Health & Development
Has/Does your child experience:
YesNo
More than two episodes of otitis media (ear infection)
Ventilatory (myringotomy) tubes (grommets)
Visual difficulty
Movement problems
Poisoning or drug overdose
Sleep problems
Hearing difficulty
Failure to thrive
Convulsions/seizures/epilepsy
Poor growth or weight gain
Consent
Treatment Consent

In your appointment, you will be asked a variety of questions to help your health practitioner gain an insight into your child's activities of daily living, function and overall general health. The information you give assists the health practitioner to generate a working diagnosis and an appropriate management/treatment plan. All our staff strictly adhere to the privacy and confidentiality act. We endeavor to treat all clients with the highest levels of empathy, respect and dignity. 

It is likely that your practitioner will also conduct an objective assessment. During this assessment and treatment, it may also be required for your health practitioner to make physical contact. Throughout the assessment or treatment, you are in control. Please let your practitioner know if you have any concerns with respect to the assessment or treatment process at any time. 

Physiotherapy, Exercise Therapy, Chiropractic and Massage Therapy are considered safe and effective forms of treatment. However, like most interventions along with the sought benefits there are possible side effects and responses to treatment that are unique to every individual. Your health practitioner will provide you with information about the recommended treatment along with associated risks and benefits. Our health practitioners are very skilled and will be able to offer you a variety of treatments to help you find outcomes you are comfortable with. 

I accept Smart Health's Terms and Conditions for assessment and treatment:
Privacy

Smart Health needs to collect information from you for the primary purpose of providing quality service, in order to thoroughly assess, diagnose and provide therapy. This information may be used for:

  • The administrative purpose of running the clinic.

  • Billing either directly through a Third Party such as an insurer or compensation agency.

  • Use within the clinic if discussing or passing your care to another practitioner within the clinic for your ongoing management.

  • Disclosure of information to your doctors or other health professionals to facilitate communication and best possible care for you.

  • In the case of an insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.

Smart Health treats all information collected confidentially and in accordance with the obligations required by the Privacy Act 1988 (Cth) (Privacy Act) to comply with the Australian Privacy Principles (APP) that regulate how private organisations collect, use, disclose, store, provide access to and destroy personal information. Details of Smart Health's Privacy Policy are available here.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. These may include your GP, specialists, allied health practitioners, or in the case of compensation claims - insurers, solicitors or employers.

I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure. I understand that it is my choice as to what information I provide an that withholding or falsifying information might act against the best interests of my assessment and therapy progress.
I accept Smart Health's Privacy Policy:
Payment

Payment is requested at time of service. We accept payment by cash or credit card.

A 24 hour cancellation notice is required if you're not able to attend the session time otherwise full payment is required for the session not attended. This will enable other clients to use the allotted time. If running late for your appointment, the session will be shortened so that the next client is not inconvenienced. 

I acknowledge and accept responsibility for payment of all appointments and treatments:
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