FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
To be completed in conjunction with Out Of Home Care Health Pathways 2a Primary Health Screen. If both parts are not com-
pleted, then the assessment is not complete.
WSHR-2262

As the child’s current carer, please take the time to fill out this questionnaire and bring the questionnaire to the ap-

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

pointment. This will help us to identify any concerns that you have which may be affecting the child’s growth
and development.

Medicare Number

General Practitioner

Practice Name

Address

Phone Number

Paediatrician

Practice Name
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Address

Phone Number

Section 1: Physical Health

Current Medications: (What, When and Who Prescribed the medication? How often did the prescriber say to take it? How
often did the child take it? Did you notice any changes (What got better or what got worse?)

Allergies: Do you know of any allergies? If there are known allergies, then this should be shared with the clinician.

Immunisation: (Are the child’s immunisations are up to date?)

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Skin Condition: (Does the child have any rashes, eczema, psoriasis, allergic reactions to different things?)

Toilet Habits: (Does the child need assistance? Are there any concerns with bedwetting or soiling?)

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Hygiene: (What is the child’s hygiene like? Do you have any concerns about the child’s hygiene?)

Eating Habits/Nutrition (Appetite: Variety of foods eaten; frequency of consuming processed food; over
eating; lack of appetite)

WSHR-2262
¶WSHR-2262uÄ

What is the Child’s Physical Activity like? (Time spent in active or energetic play; time spent in sedentary activities)

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
What is the Child’s Sleep like? (Do you or child have any concerns re sleep? Difficulties falling asleep, staying asleep,
nightmares etc.)
WSHR-2262

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

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Holes Punched as per AS2828.1: 2012

What are the Childs Energy Levels Like? (Are there any concerns about energy levels? Tiredness?)

Section 2: Developmental Health

Speech: (Refers to the pronunciation or production of speech sounds)

Is the child’s speech difficult to understand? Yes No

Does the child have a lisp or problems pronouncing any sounds in particular? Yes No

Does the child leave sounds out of words? Yes No

Give Examples of words not pronounced correctly (eg tar for car): Yes No
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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Receptive language: (Refers to the understanding of words and sentences, ability to follow directions and respond
appropriately to questions.)

Does the child misunderstand what you say? Yes No

Does the child make comments or give answers that seem off the topic of conversation? Yes No

Does the child ever look confused or follow other people when given directions? Yes No

Is there anything else you are concerned about? Please comment below. Yes No

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Expressive language: (Refers to the meaningful use of words and sentences appropriately in conversations.)

Does the child have difficulty putting sentences together correctly? Yes No

Does the child have difficulty using correct grammar (e.g. “He is running” Vs “him run”)? Yes No

Does the child sound immature for their age? Yes No

Does the child have difficulty telling stories or talking about past events? Yes No

Is the class teacher/ school counsellor concerned about the child’s language abilities? Yes No

Is there anything else you are concerned about? Please comment below. Yes No WSHR-2262
¶WSHR-2262uÄ

Stuttering: (Stuttering occurs when the natural flow of speech is interrupted.)

Does the child stutter? Yes No

Does the child get stuck on words or repeat words? For example, does their speech sound “bumpy”? Yes No

If this happens, please give an example:

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Voice: (This refers to the vocal quality of speech. A voice should sound normal for a child’s age)
WSHR-2262

Does the child’s voice sound husky? Yes No

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

Does the child sound nasal? Yes No

Has the child seen an ear nose and throat specialist? If yes, provide details. Yes No
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Holes Punched as per AS2828.1: 2012

Gross Motor Skills: (Refers to large movements of the body.)

Does the child have difficulty with ball skills (e.g. throwing, catching, kicking etc.)? Yes No

Does the child have difficulty with balance (e.g. standing on 1 foot, hopping, walking on
Yes No
balance beam etc.)?
Does the child have difficulty with movement (e.g. rides two wheeler bike, enjoys playground
Yes No
equipment etc.)?

Does the child appear clumsy (e.g. running, jumping, skipping, climbing etc) Yes No

Does the child have difficulty with posture (e.g. holds head close to desk when writing, difficulties
Yes No
sitting neatly on the floor)?

Does the child have difficulty with muscle tone (e.g. floppy, stiff arms or legs etc.)? Yes No

Do you notice any differences between the left and right side of the body? Yes No

Does the child have difficulties with walking (e.g. walks on toes, pigeon toed, knocked knees etc.)? Yes No

Is there anything else you are concerned about? Please comment below. Yes No
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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Fine Motor Skills: (Refers to small movements of hands and fingers)

Does the child have difficulty using their hands (e.g. picking up & placing small objects
Yes No
threading beads, etc.)?

Does the child have difficulty with pencil skills (e.g. colouring, drawing, and writing)? Yes No

Does the child have an awkward pencil grasp (e.g. holds the pencil incorrectly, presses too hard)? Yes No

Does the child have difficulty with hand strength (e.g. opening jars, turning on taps,
Yes No
constructing with Lego)?

Does the child have difficulty with craft skills (e.g. cutting & pasting)? Yes No

Left Handed Right Handed

Does the child consistently use the same hand for writing, cutting and throwing balls
Yes No
(i.e., hand preference)?

Is there anything else you are concerned about? Please comment below. Yes No

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BINDING MARGIN - NO WRITING

Self Help Skills: (Refers to age appropriate abilities in daily activities)

Does the child have difficulty with self-help skills (e.g. using a knife and/or fork, doing up
Yes No
buttons or shoelaces)?
WSHR-2262
¶WSHR-2262uÄ

Is there anything else you are concerned about? Please comment below. Yes No

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Learning Abilities
WSHR-2262

School

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

Teacher

Grade

Is the class teacher/school counsellor concerned about the child’s learning abilities? Yes No

Is the child in a support class? Yes No

Does the child have any special assistance with learning at school? Yes No

Is the child struggling at school? Please comment below. Yes No

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Holes Punched as per AS2828.1: 2012

Section 3: Psychosocial Health

How have they been coping at school? Have they had to change schools & if so are they managing socially? Do they
display any of the behaviours at school? If so, what is the impact on teacher, principal, academic performance, attendance,
relationships with peers/friends? Is there a behaviour management plan at school?
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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Contact Visits: (Does the carer or child have any concerns about contact with parent(s)? Are there any safety concerns?)

How has the child settled in to the placement? (How have they settled into the new environment? Behaviours,
interactions with others.)

Holes Punched as per AS2828.1: 2012

BINDING MARGIN - NO WRITING

Strengths of the child & any positive behaviours: (What does the child do well? Describe some positive behaviour’s i.e.,
WSHR-2262
¶WSHR-2262uÄ

kind to younger children, willing to follow house rules etc.)

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Presenting concerns & any behaviours of concern: (Do you have any concerns about the child at the moment?
Why do you think this is happening? Describe behaviours of concern, their frequency, onset and give examples.
WSHR-2262

And what does carer think might be helpful?)

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

Risk of Harm: (Do you have any concerns about the child harming themselves or anyone else? E.g., suicidal thoughts or
behaviour; self-harming behaviour (head banging, scratching, cutting) Any concerns about the child being harmed?)
BINDING MARGIN - NO WRITING
Holes Punched as per AS2828.1: 2012

Impact of any presenting concerns on home and family: (What is the impact on relationships with you, your partner,
siblings, relatives, friends, neighbours? Is the placement at risk? What is the impact on the child? What is the child’s
view of the problem?)

Strategies: (What has been tried to overcome the concern? How effective has this been? (Try rating effectiveness on 0-10
scale) Is there anything you haven’t tried that you think would work?)
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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Other behaviours, emotions, interactions that may be of concern: (The following are prompts to help think with carers
about other signs of concern/trauma/ mental illness that may be less obvious. Please tick boxes where you have concerns
about child and comment if appropriate.)
Is the child anxious? (e.g., general anxiety/worry, anxious when separated from carers or others,
Yes No
nightmares).

Holes Punched as per AS2828.1: 2012

BINDING MARGIN - NO WRITING
Is the child displaying aggressive and oppositional behaviours? (e.g,. physically/verbally
Yes No
aggressive towards others, non-compliant behaviours, temper tantrums, fire setting, hurting others)

Does the child have somatic complaints? (e.g., feeding – hoarding food, hiding food, stealing food,
overeating, pica, not eating, not eating age appropriate foods; sleep disturbances – trouble falling Yes No
asleep, waking during the night, nightmares). WSHR-2262
¶WSHR-2262uÄ

Does the child display disordered thought? (e.g., hallucinations, delusions, mania, thinks they are
something / someone else, hears things, sees things, strange behaviour, strange ideas) Please describe Yes No
if this is happening.

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

¶WSHR-2262uÄ
HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Does the child display poor emotion regulation? (e.g., explosive temper, suppresses emotions, avoids
Yes No
contact with others, highly disrupted behaviour following contact with family of origin)
WSHR-2262

OUT OF HOME CARE HEALTH PATHWAY - CARER QUESTIONNAIRE (5-11 YEARS)

Does the child display pseudo-mature traits? (e.g., takes on a parenting role, talks/acts like an adult,
Yes No
seeking to control others, limited help seeking)
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Holes Punched as per AS2828.1: 2012

Does the child have difficulties with relationships? (e.g., attachment, indiscriminate affection seeking,
Yes No
limited social skills)

Does the child have sexualised behaviour (e.g., touches own sexual parts inappropriately, touches
others sexual parts inappropriately, uses sexually inappropriate language, demonstrates Yes No
age-inappropriate sexual knowledge).

Does the child have attention/concentration difficulties (e.g., difficult to get to attend to tasks, easily
Yes No
distracted)
WSHR-0809

Date Questionnaire Completed

Signature of Person Completing Questionnaire

211116

Relationship of Person Completing Questionnaire to Child

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 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O.

Facility:
ADDRESS

OUT OF HOME CARE

HEALTH PATHWAY - CARER LOCATION / WARD
QUESTIONNAIRE (5-11 YEARS) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Holes Punched as per AS2828.1: 2012

BINDING MARGIN - NO WRITING
WSHR-2262
¶WSHR-2262uÄ

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