Test

History was provided by:

Parental concerns:

Patient lives with:

Recent injury or illness?

Types of intakes:

Does the patient have a dental home?

How often does the patient brush teeth?

How often does the patient floss?

When was the patient's last dental exam?

School behavior

Home behavior

How many hours of sleep does the patient get regularly?

Is there smoking in the home?

Does the home have working smoke alarms?

Are there working carbon monoxide alarms?

Is there a gun in the home?

Patient's educational performance

Immunizations

Are there risk factors for hearing loss?

Are there risk factors for dyslipidemia?

Are there risks for tuberculosis?

Are there risks for lead toxicity?

Does the caregiver enjoy the child?

After school the patient is:

Sibling interactions are

How much time does the child spend in front of a screen?

All systems negative except

Notes: