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STGKids Concerns
Date and Time of Appointment
Date
Time
Doctor to be seen
Child's First Name
First Concern
Second Concern
Third Concern
Specific Concerns
Child's Development, Growth, Hearing, Vision?
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No
Yes
If you answer "Yes" to any of the above concerns, please specify
Medications
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Family History
Mother's Name
Mother's Occupation
Father's Name
Father's Occupation
Siblings names (plus ages)
Social History
Patient is recipient of social benefits
Interpreter Needed
Language
Aboriginality Status
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Aboriginal Origin
Torres Strait Islander
Both Aboriginal/Torres St Isl. Origin
Neither Aboriginal/Torres St Isl.
Not Specified
Child Attends
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Day Care
School
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GP Details
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