How to complete this form

A parent or legal guardian should complete this form. Fill it in on your phone, tablet or computer, then press the Submit Form button at the end — your answers go straight to the clinic.

Please submit at least 48 hours before your child's appointment. Leave blank anything that doesn't apply or you're unsure of — we'll talk it through together. Email any test results, the Blue Book (child health record) pages or reports separately to health@cassandrahilton.com.

Child New Patient Form

For children from newborn to 6 years. Thank you for choosing Cassandra Hilton. Please complete the following and submit at least 48 hours prior to your child's appointment. Not every question will apply to your child's age — just skip those.

Your Child's Details

Child's First Name

Child's Last Name

Preferred Name / Nickname

Date of Birth

Age (years / months)

Sex / Gender

Street Address

Suburb

State

Post Code

Childcare / Preschool / School (if attending)

Days per week attending

Who lives in the home? (parents, siblings, others)

Language(s) spoken at home

Siblings (names & ages)

Child's position in family (e.g. 2nd of 3)

How did you hear about us?

Our website / Google Brochure/flyer Social Media Referral (name):

Parent / Guardian Details

Parent / guardian completing this form

First Name

Last Name

Relationship to child

Mobile

Email Address

Occupation

Second parent / guardian (if applicable)

First Name

Last Name

Relationship to child

Mobile

Email Address

Occupation

Private Health Fund / Medicare card holder (if applicable)

Who will attend the appointment?

Are there any custody, guardianship or parenting arrangements we should be aware of? (e.g. who can consent to treatment)

Yes No Unsure

Details

Current Health Practitioners

e.g. GP, Paediatrician, Child Health Nurse, Lactation Consultant, Speech Pathologist, OT, Chiropractor/Osteopath

GP's Name

Clinic Address

Clinic Phone Number

Paediatrician / Specialist Name

Clinic Address

Clinic Phone Number

Other Practitioner Name

Type of practitioner

Clinic Phone Number

Emergency Contact Details

Someone other than the parent/guardian completing this form

Name

Relationship to child

Phone Number

Current Health Concerns

Please list up to 5 concerns, in order of priority

When did these concerns first begin?

Has anything made them better or worse?

Prenatal Health

Questions about the mother's health before and during pregnancy, which can influence a child's immune, gut and skin health. Answer as best you can.

Preconception

How long were you planning / trying before conception?

Any fertility treatment? (type)

Were you taking any supplements in the 3 months before conception? (e.g. folate, multivitamin)

Yes No Unsure

Which and for how long

Contraception before conception

Hormonal pill / implant / injection IUD (hormonal or copper) Barrier / natural methods None

Mother's general health before pregnancy (energy, digestion, skin, cycles)

Mother's weight / BMI before pregnancy (approx.)

Father's age at conception

Father's health before conception (smoking, alcohol, conditions)

Mother's health conditions (before or during pregnancy)

Did the mother have any of the following?

Details and any treatment for the above

Nutrition during pregnancy

Which best describes the mother's diet during pregnancy?

Fish / seafood per week (type)

Dairy intake per day

Caffeine per day (coffees / teas)

Fruit & vegetable serves per day (approx.)

Fermented foods (yoghurt, kefir, sauerkraut) per week

Were any of the following consumed regularly during pregnancy?

Cravings or aversions during pregnancy

Weight gain during pregnancy (approx.)

Prenatal supplements taken during pregnancy

Did the mother take any of the following?

Infections, illness & medications during pregnancy

Illness / Infection	Trimester	Treatment (e.g. antibiotics)

Did the mother take antibiotics during pregnancy or labour?

Yes No Unsure

Which, when, and for what

Did the mother use any medications regularly (e.g. paracetamol, antacids, antidepressants, antihistamines, steroids)?

Yes No Unsure

Which, when, and how often

Mother's blood type / Rh status

Any positive test results (GBS, CMV, toxoplasmosis, etc.)

Stress, sleep & emotional health during pregnancy

Stress levels during pregnancy (1 = low, 10 = very high)

Quality of sleep during pregnancy (1 = very poor, 10 = excellent)

Did the mother experience anxiety, low mood or depression during pregnancy?

Yes No Unsure

Details and support received

Any significant life stressors during pregnancy? (loss, relocation, relationship stress, financial stress)

Yes No Unsure

Details

Environmental exposures during pregnancy

Was the mother exposed to any of the following?

Pets in the home during pregnancy

Sun / vitamin D exposure (hours outdoors per week)

Exercise during pregnancy (type & frequency)

Antenatal classes / support attended

Postnatal health of the mother

Since the birth, has the mother experienced any of the following?

Anything else about the mother's health, before or after birth, that you feel is relevant

Pregnancy & Birth History

Pregnancy

Mother's age at conception

Conception method (natural / IVF / other)

Number of previous pregnancies

Did the mother experience any of the following during pregnancy?

Any additional medications taken during pregnancy (include trimester)

Any other pregnancy details or complications

Birth

Gestation at birth (weeks)

Birth weight

Birth length

Head circumference

Type of birth

Vaginal Assisted vaginal (forceps / vacuum) Planned caesarean Emergency caesarean

Birth interventions / events

Apgar scores (if known)

Place of birth (hospital / birth centre / home)

Did your baby spend time in special care or the NICU?

Yes No Unsure

Reason and how long

Did your baby have jaundice requiring treatment?

Yes No Unsure

Details

Vitamin K

Injection Oral Declined

Hepatitis B birth dose

Given Declined

Any concerns from newborn screening (heel prick) or hearing screen?

Yes No Unsure

Details

Was your baby breastfed within the first hour (skin-to-skin)?

Yes No Unsure

Anything else about the birth or first weeks that you feel is important

Feeding History

Infants and toddlers — complete as much as is relevant; older children can skip to Growth & Development

How was your child fed in the first 6 months?

Breastfed only Formula only Combination (breast + formula) Expressed breastmilk

If breastfed: how long in total (age stopped)?

Exclusively breastfed until (age)?

Formula brand(s) used

Age formula started

Method of introducing solids

Baby-led weaning Purées / spoon-fed A mix of both Not yet started

Age solids introduced

First foods offered

Has your child had any reactions to foods? (rash, vomiting, swelling, diarrhoea, wheeze)

Yes No Unsure

Which foods and what happened

Age allergenic foods were introduced (egg, peanut, dairy, wheat, fish, etc.)

Feeding difficulties — now or in the past

If breastfeeding: does mum follow any dietary restrictions or take supplements?

Yes No Unsure

Details

Current main milk (breast / formula / cow's / plant-based)

Approximate amount per day

Dummy / pacifier use (yes/no, how often)

Bottle / sippy cup use

Growth & Development

Approximate ages are fine. Your Blue Book / child health record may help.

Milestone	Age achieved	Any concerns?
Held head up
Rolled over
Sat unsupported
Crawled
Pulled to stand
Walked independently
First words
Two-word phrases
Speaking in sentences
Toilet trained — day
Toilet trained — night

Do you have any concerns about your child's:

Assessments or therapies your child has had (speech pathology, OT, audiology, developmental paediatrician, physio, etc.)

Most recent weight (and date)

Most recent height (and date)

Growth percentile, if known

Has any practitioner raised concerns about your child's growth or weight gain?

Yes No Unsure

Details

Immunisation History

This helps us understand your child's overall picture. There are no wrong answers and no judgement.

Immunisation status

Fully up to date (Australian schedule) Partially immunised Delayed / alternative schedule Not immunised

Date of most recent vaccination

Vaccine(s) given

Has your child had any reaction to a vaccine?

Yes No Unsure

Details

Notes (e.g. vaccines planned, exemption, catch-up schedule)

Medical History

Has your child been diagnosed with any medical conditions?

Diagnosed Medical Condition	Date / Age	Who Diagnosed?

Hospital admissions, surgeries or procedures

What / Why	Date / Age	Details

Number of ear infections to date

Grommets / tonsils / adenoids removed? (when)

Courses of antibiotics in the past 12 months

Total courses of antibiotics since birth (approx.)

How often does your child get a fever or illness requiring time off childcare?

Average number of colds / infections per year

Has your child had any significant injuries, head knocks, falls or accidents?

Yes No Unsure

Details

Current medications

Medicine Name	Dose & How Often	How Long Taken?

Current supplements, probiotics, herbal or homeopathic remedies

Item Name & Brand	Dose & How Often	How Long Taken?

Allergies and intolerances — please provide details of any reaction

Food Allergies / Intolerances (e.g. egg, dairy, peanut, gluten)

Environmental Allergies (e.g. dust mite, pollen, pets, mould)

Medicine / Supplement Allergies

Systems Review

Please tick how often your child has experienced each of the following.

Digestion

Symptom	Never	In the past	Sometimes	Often
Reflux / spitting up
Colic / excessive crying
Constipation
Diarrhoea / loose stools
Wind / bloating
Tummy pain
Nausea / vomiting
Poor appetite
Very fussy eating
Undigested food in stools
Blood or mucus in stools
Offensive-smelling stools

Skin

Symptom	Never	In the past	Sometimes	Often
Eczema / dry patches
Cradle cap
Nappy rash
Hives
Unexplained rashes
Skin infections (impetigo / school sores)
Warts / molluscum
Easy bruising
Excessive sweating
Dry or cracked lips

Respiratory, Ears, Nose & Throat

Symptom	Never	In the past	Sometimes	Often
Frequent colds
Blocked or runny nose
Persistent cough
Wheeze
Croup
Asthma
Snoring
Mouth breathing
Sore throats / tonsillitis
Hay fever / sneezing
Ear infections
Glue ear / fluid in ears
Hearing concerns

Immune & General

Symptom	Never	In the past	Sometimes	Often
Frequent infections
Fevers
Slow recovery from illness
Swollen glands
Oral thrush / nappy thrush
Hand, foot & mouth / viral rashes
Food reactions
Pale / tired appearance
Cold hands and feet

Sleep

Symptom	Never	In the past	Sometimes	Often
Difficulty falling asleep
Frequent night waking
Early waking
Night terrors
Nightmares
Teeth grinding
Restless sleep / kicking
Needs a parent to settle
Bed-wetting

Behaviour, Mood & Nervous System

Symptom	Never	In the past	Sometimes	Often
Irritability
Tantrums / meltdowns
Separation anxiety / clinginess
Anxiety / fears
Difficulty concentrating
Hyperactivity
Sensory sensitivities (noise, textures, labels)
Aggression / hitting
Shy / socially withdrawn
Delayed or unclear speech
Clumsiness
Low energy / fatigue
Headaches
Repetitive movements

Growth, Teeth & Other

Symptom	Never	In the past	Sometimes	Often
Slow weight gain
Rapid weight gain
Slow growth in height
Difficult teething
Dental decay
Tongue-tie / lip-tie
Low muscle tone / floppy
Excessive thirst
Early puberty signs (body odour, pubic hair, breast development)

Digestion & Bowels

How often does your child have a bowel motion?

Consistency (soft, hard, pellets, watery)

Colour of stools

Any blood, mucus or undigested food?

Any straining, pain or holding on?

Toilet / nappy status (nappies, training, toilet trained)

Details of any digestive issues in the past

Diet & Nutrition

What does your child eat on a typical day?

Breakfast

Lunch

Dinner

Morning snack

Afternoon snack

Other / before bed

Favourite foods / cravings

Foods refused or avoided / foods that upset them

Any dietary restrictions or special diets (e.g. dairy free, gluten free, vegetarian)

Serves of vegetables per day (approx.)

Sugary foods / treats per week (approx.)

Takeaway / packaged meals per week

Is your child's eating

Good — eats a wide variety Fair — some fussiness Very restricted / selective

Sleep

Usual bedtime

Usual wake time

Total hours of sleep in 24 hrs

Daytime naps (number & length)

Where does your child sleep? (own cot/bed, room-sharing, co-sleeping)

How does your child settle to sleep?

How many times do they wake overnight?

Does your child:

Any other sleep concerns

Does your child wake refreshed?

Usually Sometimes Rarely

Mood, Behaviour & Learning

How would you describe your child's temperament?

How do they cope with change or new situations?

How would you rate your child's overall mood? (1 = often low/unsettled, 10 = happy and settled)

How would you rate your child's anxiety / worry? (1 = low, 10 = very high)

Screen time per day (hours)

What type of screens / content?

Do you have concerns about your child's behaviour, attention or learning?

Yes No Unsure

Details

Has a childcare worker, teacher or health professional raised any concerns?

Yes No Unsure

Details

What does your child enjoy? What are their strengths?

Energy & Activity

How would you rate your child's energy levels? (1 = lowest, 10 = highest)

Time spent outdoors / active play per day

Any afternoon slumps or energy crashes? (time)

Physical activity or sports (e.g. swimming, playground, kinder gym)

Environment

Is your child exposed to cigarette smoke or vaping at home or in the car?

Yes No Unsure

Details

Have you lived in a water-damaged or damp home? (flooding, leaking, mould)

Yes No Unsure

When and for how long

Are there pets in the home?

Yes No Unsure

What type?

Have there been recent renovations, new carpet/furniture, or pesticide/chemical exposure?

Yes No Unsure

Details

Home heating / cooling type

Drinking water source (tap, filtered, tank, bottled)

Laundry detergent / household cleaning products used

Nappies / wipes brand used (if applicable)

Has your child been bitten by a tick, spider or experienced an unexplained rash/bite?

Yes No Unsure

Details

Has your child travelled overseas?

Yes No Unsure

Where and when

Is there a history of lead exposure (old paint, soil) or other toxin concerns?

Yes No Unsure

Details

Family History

Mark X for conditions that a family member has experienced. Examples: asthma, eczema, hay fever, food allergies, autoimmune disease, thyroid, coeliac disease, diabetes, cardiovascular disease, cancer, depression, anxiety, ADHD, autism, learning difficulties, epilepsy, migraines, digestive issues (IBS/IBD), skin conditions, eating disorders.

Condition	Child's Mother	Child's Father	Child's Sibling	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather

Skin Conditions

Complete If Skin Is A Concern

Skin is not a concern? Skip to Consent & Agreement →

Eczema and other skin conditions in young children often involve the gut, immune system, environment and the products used on and around the skin. The more detail you can share, the more targeted the plan will be.

Primary Skin Concern

Which skin concerns does your child have?

Age at onset

Duration (how long has it been present?)

Diagnosed by (GP, paediatrician, dermatologist) & when

Has the diagnosis changed over time?

Location on body (be specific, e.g. cheeks, behind knees, scalp, nappy area)

Current overall severity (1 = mild, 10 = severe)

Eczema — Detailed Questions

Complete if your child has eczema or suspected eczema.

Areas currently or commonly affected

How does the eczema look and feel?

Itch severity (1 = mild, 10 = unbearable)

How often do flares occur? (e.g. weekly, monthly, constant)

Longest period the skin has been clear

Is the skin worse at a certain time of day?

Does it wake your child at night? How often?

What triggers flares? (tick all that apply)

Foods suspected or known to trigger the eczema

Did eczema begin or worsen when solids / new foods were introduced?

Did it change with breastfeeding or formula changes?

Has your child ever had allergy testing (skin prick, blood test, patch test)?

Yes No Unsure

Type, date and results

Does your child (or does a sibling) also have any of the following?

Has the eczema become infected (weeping, crusting, honey-coloured scabs, cold sores)?

Yes No Unsure

How often, and was it treated?

Has your child needed hospital care or a doctor visit for eczema?

Yes No Unsure

Details

Have wet wraps, bleach baths or oral steroids/immune therapies been used?

Yes No Unsure

Which, when, and result

Does scratching cause bleeding or broken skin?

Yes No Unsure

Details

What does your child wear to bed? (fabric)

Bedroom temperature / heating / cooling

Topical Skincare & Bathing

Bathing frequency

Water temperature & length of bath

Wash / soap / bubble bath used (brand)

Shampoo / hair products used

Moisturiser / emollient name & brand

How often applied, and how much (e.g. tube per week)?

When is moisturiser applied? (immediately after bath, morning, night)

Sunscreen used (brand & how often)

Nappy brand / wipes used

Nappy cream / barrier cream used

Natural remedies or home treatments used on the skin (e.g. coconut oil, oats, calendula, honey, olive oil)

Topical Treatments Tried — Including Steroids

Please list every product tried, including steroid creams (e.g. hydrocortisone 1%, Advantan, Elocon), calcineurin inhibitors, antifungals and antibiotic creams.

Product / Strength	Where Applied & How Often	How Long Used	Response / Side Effects

Has the skin flared or worsened after stopping a steroid cream?

Yes No Unsure

Details

Laundry, Household Products & Chemicals

Laundry detergent used (brand, powder / liquid / pods)

Fabric softener or dryer sheets used?

Extra rinse cycle used? Are clothes air- or machine-dried?

How often are bedding and towels washed?

Are new clothes / bedding washed before use?

Stain remover / bleach / nappy soaker used

Dishwashing liquid / dishwasher tablets

Household surface / floor / bathroom cleaners

Which of the following are present in your home or used regularly?

Do adults who handle your child wear perfume, scented deodorant or use scented products?

Yes No Unsure

Details

Have you tried changing any products? (e.g. fragrance-free laundry, new moisturiser)

Yes No Unsure

What was changed and what happened to the skin

Vaccination & Skin

Has your child's skin flared, or has eczema started, around the time of a vaccination?

Yes No Unsure

Which vaccine, how soon afterwards, and what happened

Has your child had a skin or allergic reaction at the injection site or after a vaccine?

Yes No Unsure

Details

Age eczema or skin condition first appeared relative to vaccines

Date of most recent vaccine and any skin change since

Illness, Infection & Skin

Does the skin flare during or after colds, viruses, fevers or teething?

Yes No Unsure

Details

Did the skin condition begin or worsen after a course of antibiotics?

Yes No Unsure

Which antibiotic, when, and what happened

Does your child get recurrent skin infections, boils, thrush or cold sores?

Yes No Unsure

Details

Number of colds / illnesses per year

Any gut symptoms when skin flares? (loose stools, constipation, tummy pain)

Any other illness, infection or health event that has coincided with a change in your child's skin

Gut, Diet, Sleep & Stress Correlation

Does skin flare after particular foods or drinks?

Does skin change with bowel habits?

Does poor sleep, stress or change of routine coincide with flares?

Does your child scratch more when tired, bored or stressed?

Other Skin Conditions

Complete if the main concern is not eczema (e.g. nappy rash, cradle cap, hives, molluscum, warts, fungal, impetigo, acne).

Describe what the skin looks like

Has it spread or changed? When did it begin?

Contagious contact (siblings, childcare, pets)?

Treatments tried and the result

Family History — Skin & Allergy

Do parents, siblings or grandparents have eczema, psoriasis, asthma, hay fever, food allergies or other skin conditions? Please specify who and what.

What would success look like for your child's skin?

Parent / guardian full name (typed)

Signature (type your full name to confirm)

Relationship to child

Date

Ready to send this form?

Check your answers above, then press the button below to submit your child's form directly to the clinic.

Having trouble submitting? You can instead press Ctrl/Cmd+P and choose "Save as PDF", then email it to health@cassandrahilton.com.

Please submit your child's completed form at least 48 hours prior to the appointment.

Symptom	Never	In the past	Sometimes	Often
Frequent urination
Daytime wetting
Night-time wetting
Urinary tract infections
Painful urination
Strong-smelling urine

How to complete this form

Child New Patient Form

Your Child's Details

How did you hear about us?

Parent / Guardian Details

Parent / guardian completing this form

Second parent / guardian (if applicable)

Current Health Practitioners

Emergency Contact Details

Current Health Concerns

Prenatal Health

Preconception

Mother's health conditions (before or during pregnancy)

Nutrition during pregnancy

Prenatal supplements taken during pregnancy

Infections, illness & medications during pregnancy

Stress, sleep & emotional health during pregnancy

Environmental exposures during pregnancy

Postnatal health of the mother

Pregnancy & Birth History

Pregnancy

Birth

Feeding History

Growth & Development

Immunisation History

Medical History

Has your child been diagnosed with any medical conditions?

Hospital admissions, surgeries or procedures

Current medications

Current supplements, probiotics, herbal or homeopathic remedies

Allergies and intolerances — please provide details of any reaction

Systems Review

Digestion

Skin

Respiratory, Ears, Nose & Throat

Immune & General

Sleep

Behaviour, Mood & Nervous System

Urinary

Growth, Teeth & Other

Digestion & Bowels

Diet & Nutrition

Sleep

Mood, Behaviour & Learning

Energy & Activity

Environment

Family History

Skin Conditions

Primary Skin Concern

Eczema — Detailed Questions

Topical Skincare & Bathing

Topical Treatments Tried — Including Steroids

Laundry, Household Products & Chemicals

Vaccination & Skin

Illness, Infection & Skin

Gut, Diet, Sleep & Stress Correlation

Other Skin Conditions

Family History — Skin & Allergy

Consent & Agreement