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Lip and Tongue Tie
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Frenectomy
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Lip and Tongue Tie Treatment Mackay, QLD
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Dentist
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Mackay (07) 4942 5111
OHB Medical for Children aged 18 months to 17 years
Aziz
2023-05-23T08:41:55+10:00
OHB Medical for Children aged 18 months to 17 years
Child & Parent Details
Patient First Name
*
Patient Last Name
*
DOB
*
DD slash MM slash YYYY
Practice Location
*
Please select from drop down box
Moranbah
Mackay
Marian
Which location is managing your booking?
Gender
*
---select--
Male
Female
Other
Parent/Guardian 1 First Name
*
Parent/Guardian 1 Last Name
*
Parent 1 Relationship to Child
*
Parent 2 First Name
*
(if there is no 2nd parent/guardian, please fill as N/A)
Parent 2 Last Name
*
Parent 2 Relationship to Child
*
Address
address
Postcode
*
Email
*
Mobile Phone or best contact number
*
Who can we thank for referring you to us?
*
e.g. another parent, health professional, google, social media, radio, billboard etc.
Health History
This information is collected to understand your child’s growth, development and health.
Name of GP / Medical Centre attended
*
Health History
*
ADD/ADHD or other
AIDS/HIV
Anemia
Asthma
Autism or other Spectrum Disorder
Bladder /Bowel Problems
Bleeding Issues
Cancer/Tumors
Cerebral Palsy
Chicken Pox (active)
Convulsions/Seizures
Diabetes
Epilepsy
Fainting
Hearing Impairment
Heart Problems
Hemophilia
Hepatitis
Kidney/Liver Disease
Learning Disability
Measles
Mononucleosis
Mumps
Rheumatic Fever
Thyroid Disease
Tuberculosis
No known medical concerns
Please check any boxes that apply
Any other medical condition not listed we should know about?
Is your child currently under the care of a paediatric team for any reason?
If yes, please provide Specialist's name, Profession & name of practice
Any medications or supplements taken by your child?
*
No
Yes
If Yes - please advise what medication/supplement your child takes
(please include vitamins/natural supplements)
Allergies?
*
Penicillin
Latex
Dairy
Dust/ & or Pollen
Bactrim
Nuts
Other medications
No known allergies
Please advise of any allergies not listed
Does your child experience any of the following conditions?
*
Ear infections
Tonsillitis
Swallowing/breathing issues
Food intolerances (textures/solids)
Nasal obstructions
Skin conditions like dermatitis or eczema
Congestion
Upper respiratory infections
Speech concerns
None known
If your child does have allergies or other airway issues, have you consulted with any health professional?
No
Yes
If yes, please provide which Health Professional, when & proposed support
Has your child had any surgery?
*
No
Yes
If yes, please briefly advise what type of surgery and when
Does your child have any special needs we should be aware of?
*
No
Yes
If yes - please briefly explain
Immunisations - Are they up to date?
*
No
Yes
Dental History
Is this your child's first visit to the dentist?
*
Yes 1st visit to any dentist
No
If your child has been seen at another dentist, we can arrange to have their records transferred over. Please advise who and when approximately
**Especially if any dental x-rays were previously taken, as Oral Health & Beyond will only take diagnostic images if clinically necessary.
What is the reason for your visit with us?
*
General dental
Dental emergency -pain &/or trauma
Dental Treatment under sedation required
Orthodontic assessment
Lip and Tongue Tie assessment
Has your child ever had an unfavourable dental visit?
*
No
Yes
How well does your child tolerate dental/medical care?
*
well
poorly
unsure
How many times a day is your child brushing their teeth?
*
zero
1
2
3
1 with parental assistance
2 with parental assistance
Has your child ever had any dental x-rays taken?
Yes
No
If clinically required, dental x-rays are an important part of diagnosing your child's dental health. Oral Health & Beyond uses very low dose radiation equipment. This will be discussed if needed, as your consent is required.
Is there a history of dental decay or missing teeth in the family?
No
Yes
Myofunctional/Diet/Feeding History
Has your child ever been examined for oral restrictions of the oral muscles such as tongue/lip tie?
Yes
No
Unsure
If yes, by whom?
Has your child previously had a lip & or tongue released?
No
Yes - snipped at birth by Paediatrician
Yes - later Private clinic
If private clinic, may we ask where?
As an infant, how was your child fed?
Breast no issues
Breast with issues
Bottle Expressed Milk
Bottle Formula
Tube /syringe fed
Other
Did you experience issues feeding your child as an infant?
No - was able breastfed no issue
Yes - struggled or unable to breastfeed
Bottle fed by choice
Did/does your child have any of the following issues with eating?
Gagging
Swallowing difficulty
Fussy about textures/solids
What foods does your child like for a snack?
What does your child drink on a daily basis?
What does your child drink from?
Open cup
Sippy cup
Bottle
Straw
Sleep & Developmental Questions
Has your child ever experienced any of the following?
*
Co-sleeping with parent/s
Difficulty falling asleep
Difficulty staying asleep
Loud snoring/breathing
Grinding Teeth
Gasping for air
Restless sleeping / Excessive movement during sleep
Does not seem to be well rested after sleep
Increased irritability
Constant fatigue during the day
Sleeping with mouth open
Persistent headaches
Attention deficit disorder symptoms
Mood disorder
Difficulty waking up
Poor school performance/behaviour
Learning difficulties
Sleep with head tilted backwards
Night Terrors
Bedwetting
None known
Bodywork - Has your child ever been assessed/treated by a Chiropractor, Bowen Therapist or the like?
*
No
Yes
If yes with whom and does your child still have bodywork on a regular basis?
Speech - Do you have any concerns in regards to your child's speech?
*
Yes
No
Has your child had (or current ) any Speech Therapy?
No
Yes - please add by whom & when in other box
Habits -Did or does your child have any of the following habits?
Thumb/finger sucking
Pacifier/dummy
Mouth breathing
Clothes chewing
Hair twirling/pulling
Nail biting
Blanket/comforter
Chewing straws/bottles
Developmental - Have you had any concerns in regards to your child's weight gain?
Yes
No
Is your child reaching milestones within anticipated time frames?
Yes
No - please detail in other box
Acknowledgement
I submit this medical form on behalf of my child & I understand that this information is correct to the best of my knowledge. I understand it will be held strictest confidence and only used to improve the quality of service my child receives.
Acknowledgement - Financial
*
Yes
I understand I am financially responsible and that payment is due on the day of my child's appointment. *Health Funds - I understand that my health insurance & rebates received are the responsibility of my insurer and myself. *CDBS - I understand it is my responsibility to advise if my child is eligible for benefits, limits to available funds apply and that not all dental services are covered under this government incentive. I will sign the required CDBS consent form as required.
Medicare Number including child's reference number
*
Do you have Private Health Insurance for Dental Extras?
*
Yes
NO
If Yes, please enter which Health Insurer, Member Number & Reference Number for your child
Do you have private health Insurance for hospital?
*
Yes
NO
Acknowledgement - Photographs
*
Yes I consent
No images of my child are to be used for social media
Please ask my consent prior to any photos being taken
Photos are routinely taken for dental/myofunctional, research & education purposes and in most cases these are for your child's dental records & kept on file only. Oral Health & Beyond does sometimes takes fun photos for use on social media, but will always ask your permission. I understand that if photos of my child are used, first name may be used but all other identifying information will be kept confidential. I do not expect compensation, financial or otherwise for the use of images.
Acknowledgement - Marketing
*
Yes I consent to marketing
No
Oral Health & Beyond Collective requires your contact information, including email, for appointment purposes. From time to time, promotions, competitions, events may be emailed to you. Do you consent to receive marketing material from Oral Health & Beyond Collective. *You can unsubscribe from our mailing list at any time.
Name of Parent/Guardian
*
First
Last
Date
*
DD slash MM slash YYYY
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