Special Needs Dental Intake Form

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Special Needs Dental Intake Form
Medical Information
Patients Name*
Patients Age
Parent / Guardian
Telephone (m)*
Email*
Describe the nature of your child's disability*
Does your child have any other physical challenges that the dental team should be aware of?If yes, please explain
Oral Care
Has your child visited the dentist before?
- Yes
- No
If yes, please describe
What are your dental health goals for your child?
Please describe your child's at-home dental care
Communication and Behaviour
Are there any symbols / signs that we can have available to assist with communication?
Are there certain cues that might help the dental team?
Is your child able to communicate verbally?
- Yes
- No
Does your child use non-verbal communication?
- Yes
- No
Please check any of the following that your child uses
- Mayer Johnson Symbols
- Sign Language
- Picture Exchange Communication Sysytem ( PECS )
- Sentence Board or Gestures
Will you be bringing a communication system with you?
- Yes
- No
Behaviour / Emotions
Please list any specific behaviour challenges that you would like the dental team to be aware of
Sensory Issues
Does your child prefer the quite?
- Yes
- No
Please list any specific sounds that your child is sensitive to
Is your child more comfortable in a dimly lit room
- Yes
- No
Is your child more comfortable in a clutter-free environment?
- Yes
- No
Is your child sensitive to motion and moving ( i.e. the dental chair moving up and down or in a reclining position )?
- Yes
- No
Please explain
Do certain tastes bother your child?
- Yes
- No
If yes,please list below
Does your child have any specific oral sensitivities ( gagging,gum,sensitivity,etc.)?
- Yes
- No
Please explain
Please provide us with any additional information that may help us to prepare for a successful dental experience
Preferred Location*
- Cambridge
- Waterloo
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Special Needs Dental Intake Form

Special Needs Dental Intake Form

Medical Information

Oral Care

Communication and Behaviour

Behaviour / Emotions

Sensory Issues

Avoid the sweet temptation!