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*
Which location is managing your booking?
Gender*
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
- Chemo or Radiation Treatment
- 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?*
If Yes, please enter which Health Insurer, Member Number & Reference Number for your child
Do you have private health Insurance for hospital?*
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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46859

Mon – Thur	9:00am to 5:00pm
Friday	9:00am to 4:00pm
Sat, Sun	CLOSED

OHB Medical for Children aged 18 months to 17 years

Child & Parent Details

Health History

Dental History

Myofunctional/Diet/Feeding History

Sleep & Developmental Questions

Acknowledgement

Open Hours

New Patient Forms

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