Step 1 of 8 12% Please complete this online Pre-Visit Questionnaire at least three days prior to your visit. The information will be beneficial in helping us understand your child (the patient) better. Kindly assist us by answering the following questionnaire to the best of your knowledge. We look forward to meeting you soon.Child's NameWhat they like to be called(Required)Emergency contact number:(Required)Medical HistoryMedical diagnosis (and age of diagnosis)(Required)History of seizures(Required) Yes No Date of last seizure(Required)Type of seizure(Required)Prior surgeries (Type and Year)(Required)Medications(Required)Allergies(Required)Does your child have any other physical challenges that the dental team should be aware of?(Required) ReferralWho referred you to us?(Required)Self-referredMedical DoctorDentistFriendParent support groupOnline searchOthersReferral Others (pls specify)(Required)Referring doctor’s name / clinic (if any)(Required) Understanding your child betterHow would you describe your child’s developmental condition?(Required) Mild (Level 1: Requiring support) Moderate (Level 2: Requiring substantial support) Severe (Level 3: Requiring very substantial support) Unsure / Others If others (pls specify)(Required)Which activities can your child do on their own?(Required) Toileting Tooth-brushing Bathing Hair-brushing Dressing None of the above (Completely reliant on adult to help) Name of school(Required) Your child’s communication methodsLanguage understanding(Required) Limited Some Most Speech(Required) Non-verbal Limited verbal Highly verbal Reading(Required) Non-verbal Some reading Fluent reader Complies with simple instructions(Required) Rarely Sometimes Usually What method / tools does your child use to communicate?(Required) Words Hand gestures Tablet Social Stories Visual schedules Pictures Others If others (pls specify)(Required)What are your child’s interests, or special skills?(Required)Is your child sensitive to any of the following?(Required) Loud noises Bright lights Unfamiliar smells Unfamiliar tastes Vibration Sudden movement Others (please specify) If others (pls specify)(Required)What are the best rewards for your child?(Required) Tablet time Prize / trinket from dentist Special food / meal Special outing Praise Others If others (pls specify)(Required)What helps your child cope, calms them down or make things easier?(Required)Is there anything else that you would like us to know about your child? (e.g. special diet, food / taste aversions, habits, gagging / oral sensitivity, things your child does not like/triggers etc.) What toothbrush does your child use?(Required) Manual Electric brush Who brushes for your child?(Required) Parent Helper Child No brushing Others If others (pls specify)(Required)Does your child have difficulty brushing?(Required) Yes No If yes, please specify(Required)Does your child use toothpaste?(Required) Yes, always Occasionally Never Which toothpaste do you use (brand / fluoride content if known etc.)(Required)Does your child floss?(Required) Yes Occasionally No Can you child spit / rinse?(Required) Yes Not consistent No Oral care goalsWhat kind of treatment would you like our team to provide?(Required) Routine examination and cleaning Filling / Crown Extractions A lot of work Orthodontics Others If others (pls specify)(Required)What would be your preferred way to accomplish your child’s care?(Please rank 1 to 5, most preferred to least preferred)Desensitisation / behavioural approach(Required) First Choice Second Choice Third Choice Fourth Choice Fifth Choice Sedation e.g. Nitrous oxide (Laughing gas)(Required) First Choice Second Choice Third Choice Fourth Choice Fifth Choice General anaesthesia(Required) First Choice Second Choice Third Choice Fourth Choice Fifth Choice Restraint / protective stabilisation(Required) First Choice Second Choice Third Choice Fourth Choice Fifth Choice Others (pls describe)What are your expectations for your child in our dental clinic?(Required)What would success look like for you on the first visit?(Required) Dental history and experienceMy child has been to see a dentist before(Required) Yes No Last visit date:(Required) MM slash DD slash YYYY How was the examination or treatment carried out?(Required) On the chair without restraint On the chair under restraint Sedation General anaesthesia What would be the best time for a dental appointment?(Required) Hours : Minutes AM PM AM/PM We will try our best to accommodate your preferred timing. Name (Parent / Person completing the form on behalf of patient)(Required)Information declaration and consent(Required)I certify that the above information is true and accurate and that there have been no omissions from the patient’s medical history. I consent to the taking of radiographs, study models, photographs or any other diagnostic tests in the course of diagnosis and treatment for clinical, medico-legal, educational and / or research purposes. I understand that the use of anesthetic agents, medications and medical devices embodies a certain risk. I consent and certified that all information is true and accurate(Required)Terms and condition of use (Pre-Visit Questionnaire)(Required) I agree with the Terms and Conditions of Use(Required)
