Developmental Health Screenings

Which day would you like to book for?*

Select preferred time*

Child's Full Name*

Child's DOB (DD/MM/YYYY)*

Gender*

Has the child ever been to Royal Far West?*

Does your child have an NDIS package?*

Is your child currently accessing and/or on a waitlist for any local services? If so please identify which one*

Guardian's Name*

Postal address*

Town*

Postcode*

Home phone

Mobile phone*

Email*

Medicare Number*

Medicare Card expiry date*

What is your (parent/carer) vaccination status?*

Child's reference number on Medicare Card*

What preschool/school does your child currently attend?*

What preschool/school will your child be attending next year?*

Who is your child's GP?*

GP Address*

Who is your child's dentist?*

Has your child been to see a dentist in the last 12 months?*

Is your child's immunisation status up to date?*

Is your child of Aboriginal or Torres Strait Islander origin?*

How did you hear about the Health and Developmental Screening?*

Who will be attending the Screening with the child?*

Does your child have motor skills development difficulties (e.g. handwriting, using scissors, throwing/catching a ball etc.)?*

Does your child have difficulties with speech or language? *

When was your child's last hearing test?*

What was the result of the hearing test?*

When was your child's last vision test?*

What was the result of the vision test?*

Do you have any concerns about your child's emotional wellbeing?*

Comments

Does your child have any significant behavioural difficulties?*

Comments

Does your child struggle to pay attention?*

Comments

Do you have any other concerns regarding your child?