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Test

History was provided by:
Parental concerns:
Patient lives with:
Mother
Father
Brother(s)
Sister(s)
Grandfather
Grandmother
Step-father
Step-mother
Step-brother(s)
Step-sister(s)
Recent injury or illness?
No
Other
Please Specify:
Types of intakes:
Vegetables
Meats
Fruits
Eggs
Fish
Cereals
Cow's milk
Chips
Candy
Desserts
Fast food
Soda
Juice
Does the patient have a dental home?
Yes
No
How often does the patient brush teeth?
Regularly
Not regularly
Sometimes
How often does the patient floss?
Regularly
Not regularly
Sometimes
When was the patient's last dental exam?
Last 6 months
1 year
More than 1 year
School behavior
Strong
Weak
Home behavior
Strong
Weak
How many hours of sleep does the patient get regularly?
2-3
3-5
6-8
8 or more
Is there smoking in the home?
Yes
No
Does the home have working smoke alarms?
Yes
No
Are there working carbon monoxide alarms?
Yes
No
Is there a gun in the home?
Yes
No
Patient's educational performance
Acceptable
Unacceptable
Immunizations
Up-to-date
Other
Please Specify:
Are there risk factors for hearing loss?
Yes
No
Are there risk factors for dyslipidemia?
Yes
No
Are there risks for tuberculosis?
Yes
No
Are there risks for lead toxicity?
Yes
No
Does the caregiver enjoy the child?
Yes
No
After school the patient is:
With parent
At daycare
Other
Please Specify:
Sibling interactions are
Good
Fair
Not good
How much time does the child spend in front of a screen?
1 hour
1-2 hours
3-4 hours
4 hours or more
All systems negative except
Ears
Neck
Throat
Heart
Lungs
Abdomen
Skin
Pulses
Notes:
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