PRE APPOINTMENT QUESTIONNAIRE

*Please do not use this service for urgent matters.

Please answer these questions for the patient who is being assessed in the allergy appointment. Please provide as much detail as possible in order to allow proper consideration of the urgency of the appointment. The more information you provide, the better. The information you supply will allow proper allocation of time for your appointment, to avoid appointments running over the allocated time, and will minimise the time you spend in the waiting room before your appointment. (please note that no appointments will be made without submitting this form).

Full name of patient (first name, middle name, family name) (required)

Date of birth of patient

Name of mother

Name of father

Date of birth of mother

Date of birth of father

Address

Suburb

State

Postcode

Contact email (required)

Contact phone number

Medicare card number

Position on Medicare card (child)

Position on Medicare card (parent)

Expiry Date of Medicare card

What are the main reasons for coming to the allergy clinic?

What outcome do you want to see as a result of the appointment?

What are other concerns you have about the patient’s health?

Please list all the patient’s other medical problems.

What symptoms does the patient have at present? Please tick:

Bowel problems

Nose problems

Asthma

Skin problems

Food allergy

Migraines/Headaches, 
Behaviour issues

Other (please explain)

How often do the symptoms occur?

How long have the symptoms been present?

Has the patient had allergy tests before? Please supply a copy of the results.

Has the patient had blood tests before? Please supply a copy of the results.

What triggers have set off the problem? Please list:
Food


Enviromental


Other

Is the patient eating a restricted diet or avoiding any particular foods?
Please detail the restrictions.

(For children) What is the main source/type of milk the patient is drinking?

If you have more documents/files want to send us, please upload them here:






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Please remember to bring in your child’s medical records book (“Blue Book”), and all previous records of weight and height measurements.

You will receive an automated email in response to the successful receipt of your request for an appointment.

*Ps, if you do not hear from us within 24 hours please follow up with a phone call(02 9634 8600) or email(humpty@paediatrix.com.au), in case of technical difficulties.

 

IT IS VITAL THAT THE PRIMARY CAREGIVER BRINGS IN THE CHILD, AS OTHERS MAY NOT BE FAMILIAR WITH THE CHILD’S SYMPTOMS. REMEMBER TO BRING YOUR BLUE BOOK TO THE APPOINTMENT AS THIS CONTAINS VALUABLE RECORDS OF GROWTH AND DEVELOPMENT.
In order to familiarize yourself with what a skin prick test involves, please take a look at the following links: