Paediatric Patient Health

Paediatric Patient Health Questionnaire

Patient Full Name *

Patient Weight *

Parent/Guardian Full Name *

Contact Phone Home

Contact Phone Business

Contact Phone Mobile

It is important that you answer ALL the questions as accurately as possible. All information is sought to minimise any risk to your child and will be retained as part of your child’s confidential clinical records.

Does your child have any:

Allergies to food, medicine, latex, plasters etc *

Yes
No

Allergies Detail *

Asthma *

Yes
No

Asthma Detail *

Cough, cold or chest infection *

Yes
No

Cough, cold or chest infection Detail *

Breathing problems *

Yes
No

Breathing problems Detail *

Kidney or urine problems *

Yes
No

Kidney or urine problems Detail *

Diabetes *

Yes
No

Diabetes Detail *

Has your child had:

Recent exposure in the last three weeks to childhood illnesses such as chickenpox / mumps / measles / rubella / whooping cough *

Yes
No

Recent exposure in the last three weeks to childhood illnesses Detail *

Their childhood immunisations *

Yes
No

Their childhood immunisations Detail *

Previous operations *

Yes
No

Previous operations Detail *

Been in hospital for other reasons? e.g. Asthma *

Yes
No

Been in hospital for other reasons Detail *

Problems with an anaesthetic *

Yes
No

Problems with an anaesthetic Detail *

Family members who have had problems with an anaesthetic *

Yes
No

Family members problems anaesthetic Detail *

Rheumatic fever or heart problems *

Yes
No

Rheumatic fever or heart problems Detail *

Seizures or fits *

Yes
No

Seizures or fits Detail *

Bleeding problems *

Yes
No

Bleeding problems Detail *

Skin problems *

Yes
No

Skin problems Detail *

General & On Discharge

Was your child born prematurely *

Yes
No

Was your child born prematurely Detail *

Was she/he admitted to the Special Care Unit *

Yes
No

Was she/he admitted to the Special Care Unit Detail *

Does your child have any other medical, developmental, behavioural conditions? *

Yes
No

Does your child have any other medical, developmental, behavioural conditions? Detail *

Is your child taking any medication? *

Yes
No

Is your child taking any medication? Please list *

Does your extended family have any other medical conditions or allergies (e.g. bleeding disorders etc)? *

Yes
No

Does your extended family have any other medical conditions or allergies (e.g. bleeding disorders etc)? Please list *

Do you have any specific questions for the anaesthetist? *

Yes
No

Do you have any specific questions for the anaesthetist? Please outline *

Do you have your own transport? *

Yes
No

Do you have access to Emergency Health Services? *

Yes
No

Declaration

Information is correct *

To the best of my knowledge the above information is correct and I authorise the use of this information for purposes directly related to my healthcare

Name

Freephone: 0800 AKL EYES (0800 25 53 93)
Email: admin@aucklandeye.co.nz
Address: 8 St Marks Road, Remuera 1050, Auckland, NZ