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Lawrence Dental Solutions

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Home Observation Form

There are many things about your child’s health that are important to know, but that I often don’t get to see at the office. Also, there are signs to look for that you may not have known were connected to your child’s teeth or health. By looking for the tracking these “signs and symptoms” , we can have a more complete picture of your child’s overall health.
You don’t have to spend a lot of time with this assessment tool, just observe their behavior at different times of day. You want to see their most natural behaviors, therefore try not to let your child know that you are watching.
While sitting around... (Watching TV, in the car) Does your child:
Put “things” in the mouth a lot (toys, sleeves, pencils, fingernails, etc.) Yes No
Lick or suck on their lips. Yes No
Have the lips apart, or even a little. Yes No
Stick or dart the tongue out of the mouth. Yes No
Have the tongue resting between the teeth. Yes No
Lean the cheek on a hand. Yes No
Breath with his mouth open, even a little bit. Yes No
Make noises when breathing. Yes No
Have trouble sitting still. Yes No
While talking...Does your child:
Talk very fast Yes No
Talk very slow Yes No
Gasp for air Yes No
Have lisp Yes No
Take speech lessons Yes No
During a meal...Does your child:
Gasp for air while eating. Yes No
Stick his tongue between his teeth when swallowing. Yes No
Stick the tongue out to meet the drinking glass. Yes No
Drink a lot while eating. Yes No
Make noises when chewing. Yes No
Eat sloppily. Yes No
Take a breath before drinking. Yes No
Puff the cheeks out when drinking. Yes No
Make the lips purse when swallowing. Yes No
Make the chin “crinkle” when swallowing. Yes No
Bob the head when swallowing. Yes No
Have trouble sitting still. Yes No
While sleeping...Does your child:
Have the mouth open. Yes No
Snore. Yes No
Wet the bed. Yes No
Toss and turn. Yes No
Tilt the head back. Yes No
Wake up frequently. Yes No
Have frequent nightmares. Yes No
Have abnormal sleep issues. Yes No
Grind the teeth. Yes No
Have trouble waking up. Yes No
Wake with dark circles under eyes. Yes No

Medical History

Does your child OFTEN (more than “once in a while”) complain of:
Stomachaches Yes No
Headaches Yes No
Ear aches: Ringing ears Dizziness Stuffy ears Itchy ears
Neck aches Yes No
A runny nose Yes No
A sore throat Yes No
Trouble swallowing pills Yes No
Dry or chapped lips Yes No
Sore teeth or gums Yes No
Sores in the mouth Yes No
Did your child ever:
Use a pacifier? Yes No Until age?
Suck a finger or thumb Yes No Which?
Food allergies
Skin allergies
Seasonal allergies
Take medication for allergies
Have asthma? Yes No See a doctor about asthma
Have learning problems Yes No
Have attention problems Yes No
“issues” at school Yes No
As a baby was your child
Early to get teeth Yes No
Late to get teeth Yes No
Hard to feed Yes No
Refusing to chew food Yes No
Prone to ear infections Yes No
Did YOU (as the parent) ever:
Have crooked teeth Yes No
Have braces Yes No
Have extractions for braces Yes No
Have allergies Yes No
Have asthma Yes No
Have TMJ or jaw problems Yes No

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