Pre-consultation Medical Form -

Pre-consultation Medical Form

Thank you for arranging a private consultation with Dr Halbert. We would be grateful if you could please complete the below pre-consultation form, before the consultation with Dr Halbert. We have found this particularly useful in terms of saving time and enabling us to focus on the key issues during the consultation. We would also be grateful if you could familiarise yourself with the terms and conditions at the bottom of the form.

Pre-consultation Medical Proforma

Updates

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Child's name

Child's date of birth

Gender

Home address

NHS number

Parent/s or carer/s names

Who has parental responsibility

Telephone number

Email (used for sending correspondence and consultation letter)

Name of person completing this form and relationship to child

Name of GP

GP Practice name and address (including post code)

GP Practice email

Reason for consultation: Where relevant please include details of any symptoms (both presence and absence of)

Please describe any symptoms that your child may have including duration of symptoms / when these started, time frames and the frequency and severity. When doing so please consider the following symptoms: Cough, shortness of breath, wheeze, runny nose, sore throat, sore ears, palpitations (feeling fast heart beat), chest pain, change in colour (pale, red, blue), headache, dizziness, faints, fits, pain, pins and needles, numbness, weakness, abdominal pain, diarrhoea (loose stool, increased number of stools), constipation, blood in stool, nausea, vomiting, diet and water intake, bed wetting, wetting in the daytime, pain on passing urine, drinking more, thirsty, passing more urine, rashes, joint pain, swelling, stiffness, lumps, bleeding, bruising, lethargy, fevers, night sweats

Pregnancy history: Please describe any concerns, or anything noted on antenatal scans

Birth history: Gestation (number of weeks born)

Mode of delivery

Vaginal

Caesarean section

Any problems at birth

Diet (breast fed, formula fed, balanced diet, any concerns with diet)

Growth

Any concerns (short stature, tall, under-weight, obese)

Concerns with puberty. Please write n/a if this does not apply due to age

Please document birth weight, length and head circumference

Current weight and height

Development

Are there any concerns with gross motor, fine motor, speech and language, hearing, vision, emotional & social development

Mental health concerns

Behavioural concerns

Past medical history

Any known medical problems

Previous medical treatments

Previous surgeries

Immunisations (up to date)

Yes

Any regular routine medications

Allergies including to any medications

Travel history especially outside Europe, when, where

Family history of medical problems (in particular parents, siblings and grandparents)

School

Name of school

Any concerns at school

Any difficulties at school including bullying

Social circumstances

Who does the child live with

Any social concerns including alcohol or substance use

Current / previous involvement with social services / safeguarding concerns

Previous investigation results

Please document here anything that you would prefer not to be discussed in front of your child

If possible, please email to the practice manager at office@childrenswellnescentre.co.uk a copy of previous investigation results (including blood tests, urine tests, x-rays, ultrasound scan reports, CT and MRI reports)

Alternatively please bring a copy of the reports to the consultation.

Please bring your child’s Red Book which includes details about their birth weight and growth to the appointment.

It would also be very helpful if you could email, before the consultation, copies of the following documents:

1. GP or specialist referral letter (if you have one)

2. Any consultation letters you may have from previous appointments / admissions at other hospitals (NHS or private)

Please read the following statements then tick the boxes to show your consent to the following:

I agree for my child to be seen by Dr Jay Halbert at The Children’s Wellness Centre. I understand I can withdraw my consent at any time, although withdrawal of consent will not necessarily be reflected in the fees due

I understand that Dr Jay Halbert is providing treatment as an individual provider and that he has full responsibility for carrying out the regulated activity

If appropriate, I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child’s development

I agree to the use of electronic communication. All official documents will be password protected and saved as a PDF

I understand that all paperwork and notes are owned and securely stored by Dr Jay Halbert in accordance with GDPR. Consultation reports and letters are not stored internally by The Children's Wellness Centre

Terms and Conditions for Consultations within The Children's Wellness Centre

Please read each section carefully, including the cancellation policy.

By ticking the following checkboxes, the client is accepting the terms and conditions below

Dr Halbert will adopt a patient-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

Dr Halbert is DBS checked and holds Professional Indemnity insurance, practicing within the framework of his profession and registrations

Dr Halbert reserves the right not to accept a referral, terminate an appointment or not to circulate a consultation report if the referral appears to be outside his area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Payment for Medical Consultations is required at the time of booking, to secure the space

We operate a strict 48 hour cancellation policy. Failure to cancel an appointment within this time frame will mean that the fee is still due

For any clients claiming through their health insurance, payment must be settled directly with The Children's Wellness Centre by the client and if appropriate, can be reclaimed via their insurance provider, using the receipt we can provide

I confirm I have read The Children's Wellness Centre policies (Privacy, Information Sharing, Confidentiality, Complaints, Zero Tolerance, Covid-19 and Illness policies), accessed via the policies page

I can confirm I have read The Children’s Wellness Centre full terms and conditions found at https://childrenswellnesscentre.co.uk/terms-conditions/