Mayfair Family Dentistry

Patient Information

Patient Name:

Parent / Guardian:

Phone Number:

Insurance:

Medical History:

Describe the Nature of Patient's Disability:

Are they currently taking any medications, vitamins, herbal, and mineral supplements?

Yes No

If Yes, please list:

Has patient ever had seizures?

Yes No

If Yes, Type of Last Seizure:

Date of Last Seizure:

Allergies:

Yes No

If Yes, Please Explain:

Hearing Aids?

Yes No

Does patient have any other physical challenges that the dental team should be aware of?

Oral Care

Has patient visited the dentist before?

Yes No

If yes, please list date:

Please describe patient's at-home dental routine:

Please list the toothbrush type used by the patient:

Electric Toothbrush Manual Toothbrush

Does the patient floss?

Yes No

Does patient need assistance when brushing their teeth?

Yes No

What are dental health goals that you would like to see for patient?

How often does patient eat during the day?

3 meals a day

Snacks in between meals

Eats only when hungry

What types of foods does patient eat?

Does patient drink soda?

Yes No

Does patient drink fruit juice?

Yes No

Communication and Behavior

Is patient able to communicate verbally?

Yes No

Are there certain visual or verbal cues that might help the dental team?

Yes No

If yes, please explain:

Are there any useful phrases or words that work best with patient?

Yes No

If Yes, please describe:

Does patient use non-verbal communication?

Yes No

Will you be bringing a communication system with you?

Yes No

If yes, please explain:

Will you be bringing visual supports to help patient during the visit?

Yes No

If yes, please explain:

If no, are there any supports that we can have available to assist with communication?

Behavior / Emotions

Please list any specific behavioral challenges that you would like the dental team to be aware of:

(Feel free to bring motivating items that are comforting and/or pleasurable for patient to dental visit.)

Sensory Issues

Please list any specific sounds that patient is sensitive to:

Does patient prefer the quiet?

Yes No

Is patient more comfortable in a dimly lit room?

Yes No

Is patient sensitive to motion and moving (i.e. the dental chair moving up and down or to a reclining position?)

Yes No

If yes, please explain:

Does patient have any oral sensitivity (gagging, gum sensitivities, grinding, clenching)?

Yes No

Is patient more comfortable in a clutter free environment?

Yes No

If yes, please explain:

What frightens patient?

What calms patient?

Please provide your dentist with any additional information that may help prepare for successful oral health care.

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Lakisha Arif-Holmes

DDS, Mayfair Family Dentistry

Dr. Arif-Holmes attended Marquette University School of Dentistry and earned her Doctor of Dental Surgery in 2008. Upon graduation, Dr. Arif-Holmes continued her education further and completed a one year General Practice Residency at Indiana University in Indianapolis, IN where she gained great experience in working with medically compromised patients as well as patients who have cognitive, intellectual and developmental disabilities.

+1-414-259-0665
www.mayfairfamdentistry.com
11127 West Bluemound Road, Wauwatosa, Wisconsin, 53226, US