Volume 8 • 2021 • Issue 3

DentalOfficePre-VisitQuestionnaire forParents/CaregiversofPersonswith SpecialHealthCareNeeds Thisquestionnaire is intended to capture information aboutpediatricpatients, but it can alsobeused or adapted for adultpatientswith specialhealth careneeds. Thepurposeof this form is to share importantdetailsabout your child’smedicalhistory,oral care routine,dietpreferences, communicationabilitiesandsensorysensitivitieswith thedental team.This informationwillhelp thedental teamprepare to make thedentalvisit as comfortable aspossible for your child.Please return the completed form to thedental officebefore your child’s scheduled appointment.When completed, this formwill contain your child’spersonalhealth information.Since regularemail isnot secure,donotemail the completed formsback to thedentaloffice.Yourdentalofficemayhavea secure portal tosubmitpersonalhealth informationandcompleted forms.Besure toaskabout itanduse theportal toconveniently and securely submit the information.Alternatively,pleasedrop the completed forms off at thedental office or sendbymail. Reminder: It’s always important to provide informed consent.Parents and caregivers are encouraged to be present at the appointment to give informed consent for care to be provided. Should another individual, such as a guardian or sibling, accompany your child/the person you are caring for at the appointment, then consent for treatment should be arranged in advanceof theappointment.Writtenconsent ispreferred;however, itcanalsobedoneverbally throughdirectcommunication with the oralhealth careprovider.Thepatient’s filewillbedocumentedwith this important information. PatientName: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ DIAGNOSISANDMEDICATIONS: 1. Describe thenature of your child’sdiagnosis/specialneeds: ________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Please list anymedications,vitamins, andherbal ormineral supplements your child is taking: ________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ORALCAREATHOMEAND INTHEDENTALOFFICE: 3. Has your childvisited thedentistbefore?  No  Yes (If yes,please listdate) _____________________________________________________________________________________ 4. Pleasedescribe your child’s at-homedental routine: ________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ 5. Does your childuse an  electronic or  manual toothbrush? 6. Does your childfloss?  No  Yes 7. Does your childneed assistancewhenbrushing their teeth?  No  Yes 8. Does your child tolerate havingX-rays taken?  No  Yes  Unknown (If ye s, please describewhat has previously workedwell to improve the experience for your child.) ____________________________________________________________ __________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ 1/4 GETTINGSTARTED. OralHealthCare forPersonswithAutism SpectrumDisorder,Alzheimer’sDisease,orDementia Tips forparentsandcaregivers tomakeoralhealthcareathomeaseasyaspossible forpersonswithspecialhealthcareneeds Getting Started: New Resources on Oral Health Care for Persons with Autism Spectrum Disorder, Alzheimer’s and Dementia CDA has launched new resources for parents, caregivers and the dental team who care for persons with intellectual and cognitive disabilities. For this project, about 1,500 dentists across Canada were surveyed on how to further improve communication and access to quality oral health care for patients with special needs, sharing their views on areas where training or support was needed. E stablishing an oral care routine at home and visiting the dentist can be challenging for persons with special health care needs. The Getting Started resources aim to provide practical guidance to parents, caregivers and the dental team who care for persons with Autism Spectrum Disorder, Alzheimer’s and Dementia. Available in English and French, the resource package includes two printable brochures—one for parents and caregivers, the other for dentists and the dental team—and a pre-visit questionnaire. 18 | 2021 | Issue 3