Parental Questionnaire

Name of Patient *

Email Address *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Age *

Mobile Phone Number *

Mothers Name *

Siblings - names & ages *

MEDICAL HISTORY

Fathers Name *

FATHER - medical history *

Illness in Paternal side of family *

How many amalgam fillings does the clid have? when were they placed? *

Pregnancy & Birth

Any medical procedures during pregnancy? *

Childs Place of birth *

Difficulty of labour? *

Other events at birth *

MOTHER - medical history *

Illness in Maternal side of family *

Any amalgam fillings placed in the mother during pregnancy or breastfeeding? *

Any unusual event during pregnancy? *

Type of delivery? *

Birthweight. *

Condition of child at birth. *

Breastfed? *

YES NO

Breastfed for how how long? *

Fevers *

Antibiotic history and any reactions. *

Surgery *

Seizures - age & circumstances *

Any disorders since birth? *

Allergies *

Injuries *

Infections *

Vaccination History *

INFANT Eating Patterns *

TODDLER Eating Patterns *

CURRENT Eating Pattern *

Favourite foods/ textures *

Most disliked foods *