Well Checks - 4 to 10 Years

Please complete this school-aged wellness check form before your scheduled appointment with Virtual Child Health. This helps us review your child's health, behaviour, school progress, sleep, and any concerns you would like to discuss during the consultation.

If your child has difficulty breathing, blue lips, severe drowsiness, a seizure, or any other severe or rapidly worsening symptoms, seek urgent medical care immediately.

Parent or guardian details

Parent or guardian full name*

Address where the child will be during the visit*

Child details

Child's full name*

Telehealth consent

I consent to a video telehealth visit for my child. I understand the limits of telehealth, that some assessments and any vaccines or tests may require an in-person visit, that the clinician may recommend urgent in-person care if needed, and that privacy will be protected as far as possible.

Previsit history

Physical activity, play, and exercise

Behaviour, attention, or emotional wellbeing concerns

Socialisation or friendships concerns

Any chronic health conditions, such as asthma, diabetes, eczema, constipation, or others?

If your child has a chronic condition, is there an action plan or recent monitoring information?

What concerns would you like addressed during this visit?*

Screeners

I understand that a behavioural or emotional wellbeing screener, such as PSC-17, may need to be completed if requested or provided before the visit.

I understand that if my child has a chronic health condition, an additional condition-specific questionnaire may also be requested before the visit.

Have you completed the relevant screener(s), if provided?

Please selectYesNoNot yet sent to me

Visit preparation

Please confirm you will try to have these ready for the visit

Any recent growth measurements if availableSchool information or teacher feedback if relevantMedication list or action plan if relevantA quiet well-lit roomPhone or device fully charged

Optional: is there anything specific you would like us to focus on during the visit, such as school progress, attention, behaviour, sleep, friendships, or a chronic condition review?

Consents

I confirm that I am the parent or legal guardian of this child, or I have authority to complete this form and arrange this appointment on their behalf.

I consent to Virtual Child Health storing and processing the information submitted in order to respond to my enquiry, arrange the appointment, and document the visit in the medical record in line with the clinic privacy policy.

Seek urgent medical care if your child has difficulty breathing, blue lips, severe drowsiness, a seizure, sudden worsening of a chronic condition, or any other severe or rapidly worsening symptoms.