Paediatric Dental Pre-Visit Questionnaire

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 Name

What they like to be called(Required)

Emergency contact number:(Required)

Medical History

Medical diagnosis (and age of diagnosis)(Required)

History of seizures(Required)

Yes

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)

Referral

Who referred you to us?(Required)

Referral Others (pls specify)(Required)

Referring doctor’s name / clinic (if any)(Required)

Understanding your child better

How 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 methods

Language 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

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

Can you child spit / rinse?(Required)

Yes

Not consistent

Oral care goals

What 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 experience

My child has been to see a dentist before(Required)

Yes

Last visit date:(Required)

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

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)

Child's Name

Medical History

Referral

Understanding your child better

Your child’s communication methods

Oral care goals

What would be your preferred way to accomplish your child’s care?

Dental history and experience

Our Group

Quick Links

Services

Contact Us

Corporate Healthcare

Feedback

Address: