Fiona Stanley Fremantle Hospitals Group - FSH Paediatric Outpatient Pre-appointment Questionnaire

If you selected "Other reason", please provide further information:

With your child's daytime wetting, do they have any of the following symptoms? (Select all that apply) Urine infections Pain on urination Urgency (needing to rush to the toilet) Straining (needing to push hard to urinate) Weak stream Incomplete emptying Stop-start stream Dribble after urinating Continuous leaking of urine Bed-wetting Constipation None of these symptoms Has your child ever been completely toilet trained? Yes No Not sure

With your child's constipation, have they experienced any of the following? (Select all that apply) Abdominal pain Rectal pain Straining Prolapse Feeling of incomplete emptying Blood in their stool Mucus in their stool Diarrhoea Toileting refusal Soiling (accidents with their bowels) Day or nighttime wetting (urine) Change in appetite (increased or decreased) Other (please describe below) None of these symptoms

Please describe "other" symptoms experienced with your child's constipation:

Please select the types of nutrition that your child takes (select all that apply): Breast milk Formula Cow's milk Solids - puree Solids - chunky mash Solids - finger foods Solids - usual family foods Other fluids - water Other fluids - juice Other fluids - soft drinks/cordial

How many bottles/cups of milk does your child have per day (number and size of each bottle)?

Please describe your child's typical breakfast: Please describe your child's typical lunch: Please describe your child's typical dinner: Please describe your child's typical snacks:

Has your child had an allergic reaction to any of the following? (please select all that apply) Milk Eggs Peanut Soy Fish Seafood Wheat Dogs Cats Other (please describe below) None of these

If your child has reacted to "other", please describe:

What symptoms did your child have when they had their allergic reaction? (please select all that apply) Sneezing Runny or blocked nose Rash Lip swelling Eyelid swelling Vomiting Diarrhoea Tingling mouth Difficulty/noisy breathing Difficulty/noisy breathing Sensation of throat tightness Wheeze Cough Hoarse voice Dizziness/collapse Pale/floppy None of these reactions

Please describe other symptoms when your child had their allergic reaction:

Please tick the foods that your child has eaten WITHOUT having an allergic reaction? (select all that apply) Egg Milk (dairy, yoghurt, cheese) Peanut Almonds Cashews Walnuts Hazelnuts Pecans Macadamias Fish Seafood (e.g. crab, prawn) Soy (e.g. soy sauce, soy milk) Wheat (e.g. bread, pasta) Sesame (e.g. hummus, sesame seeds) None of these foods

Does your child experience any of the following when they are WELL (no cold or flu symptoms)? (select all that apply) Waking at night with cough or shortness of breath Limits to exercise due to cough or shortness of breath Limits to normal daytime activity due to cough or shortness of breath Cough or choking with drinking liquids Cough or choking with eating solids Noisy breathing Runny/blocked nose Needs to use puffer/inhaler to help with breathing Other (please describe below) None of these

Please describe other symptoms experienced with asthma/breathing:

Which doctor/s have they seen and when? (Please bring any relevant letters to the appointment)

Please list all previous investigations/tests your child has had (and please bring relevant reports to your appointment if available):

Please describe any other concerns you have for your child:

How many weeks' gestation was your child born?

If you have had developmental concerns, what are these? (Select all that apply) Speech and language Hearing Vision Gross motor (e.g. sitting, rolling) Fine motor (e.g. using hands to pick things up) Socialisation

How many hours per day does your child use or watch a device?

Please list any current/past medical issues

Which medications your child is taking? (Please list all)

Which drug allergies does your child have?

What has your child been admitted to hospital for?

What surgery has your child had?

Which doctors does your child see? (Please list all)

Please list any significant family history

Which year group and school does your child attend?

Paediatric Outpatient Pre-appointment Questionnaire

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