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h
S
Q
Q
BT
8 0 0 8 333.2731 471.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
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W n
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h
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BT
8 0 0 8 359.3068 471.1832 Tm
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[(Epilepsy, seizur)4 (es, fainting ...........................................................\
.....................)]TJ
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( )Tj
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h
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BT
8 0 0 8 333.2731 458.6832 Tm
[(Y)88.9 (es )]TJ
ET
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h
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BT
8 0 0 8 359.3068 458.6832 Tm
(No)Tj
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[(Cer)3.9 (ebral palsy or developmental delay .....................................\
..................)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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h
S
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Q
BT
8 0 0 8 333.2731 446.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
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h
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BT
8 0 0 8 359.3068 446.1832 Tm
(No)Tj
-39.288 -1.562 Td
[(Autism Spectrum Disor)6.1 (der or sensory sensitivities .........................................)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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BT
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[(Y)88.9 (es )]TJ
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h
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BT
8 0 0 8 359.3068 433.6832 Tm
(No)Tj
-39.288 -1.562 Td
[(V)-4.9 (ision pr)4 (oblems .................................................................\
................................)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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h
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BT
8 0 0 8 333.2731 421.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
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h
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BT
8 0 0 8 359.3068 421.1832 Tm
(No)Tj
-39.288 -1.562 Td
[(Speech or hearing pr)4.1 (oblems .................................................................\
.........)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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h
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BT
8 0 0 8 333.2731 408.6832 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
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h
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BT
8 0 0 8 359.3068 408.6832 Tm
(No)Tj
-39.288 -1.562 Td
[(Emotional or psychological pr)4.1 (oblems ............................................................)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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0.21 0.27 1 0 K
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h
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BT
8 0 0 8 333.2731 396.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
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h
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BT
8 0 0 8 359.3068 396.1832 Tm
(No)Tj
-39.288 -1.562 Td
(Congenital birth defects ...............................................\
..................................)Tj
/Span<>> BDC
( )Tj
EMC
ET
q
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W n
0.21 0.27 1 0 K
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h
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BT
8 0 0 8 333.2731 383.6832 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
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h
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BT
8 0 0 8 359.3068 383.6832 Tm
(No)Tj
-39.288 -1.562 Td
(Cleft lip or palate ....................................................\
.........................................)Tj
/Span<>> BDC
( )Tj
EMC
ET
q
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h
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BT
8 0 0 8 333.2731 371.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
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W n
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h
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BT
8 0 0 8 359.3068 371.1832 Tm
(No)Tj
-39.288 -1.562 Td
[(Malignant hyperther)-27.7 (mia ....................................................................\
.............)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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h
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BT
8 0 0 8 333.2731 358.6832 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
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2.049 -2.647 0.407 -1.005 0 0 c
h
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BT
8 0 0 8 359.3068 358.6832 Tm
(No)Tj
-39.288 -1.562 Td
(Other medical condition ................................................\
.................................)Tj
/Span<>> BDC
( )Tj
EMC
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q
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h
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BT
8 0 0 8 333.2731 346.1832 Tm
[(Y)88.9 (es )]TJ
ET
q
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h
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BT
8 0 0 8 359.3068 346.1832 Tm
(No)Tj
-39.288 -1.562 Td
[(Is par)4 (ent or patient pr)4 (egnant .................................................................\
.........)]TJ
/Span<>> BDC
( )Tj
EMC
ET
q
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h
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BT
8 0 0 8 333.2731 333.6832 Tm
[(Y)88.9 (es )]TJ
ET
q
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W n
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h
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8 0 0 8 359.3068 333.6832 Tm
(No)Tj
-0.008 Tw -39.288 -6.085 Td
[(1. When and wher)4 (e was your child\222s last dental visit? _______________)]TJ
0 Tw 0 -1.5 Td
(__________________________________________________________________)Tj
0.023 Tw 0 -1.5 Td
(2. What was the purpose of that visit? _____________________________)Tj
-0.077 Tw 0 -1.5 Td
[(3. W)46.9 (er)3.9 (e x-rays taken at your child\222s last dental visit? ........... )]TJ
ET
q
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h
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BT
8 0 0 8 273.0359 249 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
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-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
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BT
0 Tw 8 0 0 8 297.8401 249 Tm
(No)Tj
-0.066 Tw -31.605 -1.5 Td
[(4. )0.5 (Did )0.5 (your )0.6 (child )0.5 (have )0.5 (dif\037culty )0.6 (cooperating? )0.6 (.................... )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
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h
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Q
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BT
8 0 0 8 272.8701 237 Tm
[(Y)88.9 (es )0.5 ( )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 292.9522 242.9777 cm
0 0 m
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2.049 -2.647 0.407 -1.005 0 0 c
h
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Q
BT
0 Tw 8 0 0 8 297.8401 237 Tm
(No)Tj
-0.066 Tw -31.605 -1.5 Td
[(5. W)49.8 (as/is your child bottle fed? ...........................................\
.. )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
8 0 0 8 272.8658 225 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 292.9522 230.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
0 Tw 8 0 0 8 297.8401 225 Tm
(No)Tj
-0.086 Tw -31.605 -1.5 Td
[(6. W)49.8 (as/is your child br)3.9 (east fed? ............................................. )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 268.2874 218.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
8 0 0 8 273.1753 213 Tm
[(Y)88.9 (es )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 292.9522 218.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
0.407 -5.103 2.021 -3.59 3.054 -3.054 c
2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
0 Tw 8 0 0 8 297.8401 213 Tm
(No)Tj
0.021 Tw -31.605 -1.5 Td
[(7. If you child has been )0.5 (weaned please indicate at what )0.5 (age: _____)]TJ
0.068 Tw 0 -1.5 Td
[(8. )0.6 (When )0.6 (does )0.6 (your )0.5 (child )0.6 (brush )0.6 (his/her )0.6 (teeth? )0.6 (.............. )]TJ
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 260.7652 194.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
0.407 -5.103 2.021 -3.59 3.054 -3.054 c
2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
-0.277 Tw 8 0 0 8 266.4531 189 Tm
[(Upon )-344.4 (rising )]TJ
0 Tw ( )Tj
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 49.3852 182.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
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Q
BT
-0.021 Tw 8 0 0 8 54.7531 177 Tm
(After eating any food )Tj
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 146.4628 182.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
8 0 0 8 152.3107 177 Tm
(Right after meals )Tj
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 225.4785 182.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
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2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
8 0 0 8 231.1664 177 Tm
[(Befor)3.9 (e going to bed)]TJ
-0.113 Tw -23.271 -1.5 Td
(9. Do you assist/supervise your child\222s brushing? .................. \
)Tj
ET
q
0 0 630 810 re
W n
0.21 0.27 1 0 K
/GS0 gs
q 1 0 0 1 268.7213 170.9777 cm
0 0 m
-0.407 -1.005 -2.049 -2.647 -3.054 -3.054 c
-2.049 -3.462 -0.407 -5.103 0 -6.108 c
0.407 -5.103 2.021 -3.59 3.054 -3.054 c
2.049 -2.647 0.407 -1.005 0 0 c
h
S
Q
Q
BT
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(........................................................................\
.......................... )Tj
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[(Y)88.9 (es )]TJ
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( )Tj
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[(chips, )0.6 ( )0.5 (etc.?...................................................................\
..... )]TJ
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( )Tj
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(........................................................................\
......................... )Tj
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[(Y)88.9 (es )0.6 ( )]TJ
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[(Y)88.9 (es )]TJ
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[(Y)88.9 (es )]TJ
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(________________________________________________________________________\
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[(be r)3.9 (ender)3.9 (ed. I give my consent to Dr)73 (. James C. Johnson, Dr)73 (. Blake R. Schow and their staf)-2.9 (f to per)-47.8 (for)-27.8 (m such tr)3.9 (eatments, services, medication, )]TJ
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( )Tj
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