OHB Medical for Children aged 18 months to 17 years - KIDS

Child & Parent Details

Patient First Name*

Patient Last Name*

DOB*

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*

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?*

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?*

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?

Sleep & Developmental Questions

Has your child ever experienced any of the following?*

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*