Child Assessment Proforma

If we follow a script or proforma during history taking, then we’re less likely to miss things. This is important for diagnosis and treatment planning. In this article, we outline some of the key elements of a standard child assessment proforma. Then we think about the additional questions needed for a trauma assessment.

General Proforma

General information

Date of birth Residential Address
Are they registered with a doctor
Who is with them, and do they have parental responsibility

The basics – who is in front of you, can the accompanying adult give consent etc etc. Don’t do anything until this is established.

Why are they here?

What is the patient’s complaint, in their own words.

If they have been referred to you, what was the reason given by the referrer?

What is the history of the problem?

Wherever possible, try and listen to the child rather than the parent.

Medical History

Medical history
Any medications
Allergies, Immunisations, Pregnancy/Birth/immediate post-natal history (important for MIH and other chronological defects)

Dental History

Previous types of treatment at the dentist (eg fillings, extractions etc.). Was sedation or general anaesthetic required?

This is a good opportunity to note any fears or phobias related to dentistry and gauge their potential cooperation.

Social/Family History

Who do they live with?

Any related dental problems in any other family members?

What school do they go to?

Any involvement with social services?

These questions are key to gauge family attitudes to treatment and whether there are any social or safeguarding concerns. If you ask everyone the social services question, then it makes it less difficult to pick up those children who might already be known.

Oral Habits

Toothbrushing — how often, who does it?
Toothpaste – is it fluoridated? What strength? Do they spit or rinse with water after? Any other habits eg digit sucking, nail-biting, etc?

If you only ask one question, ask about fluoride toothpaste strength and frequency of use

Diet History

What do they snack on?
What do they drink when they are thirsty?
Do they use a cup, beaker or bottle?
Are they still breastfeeding?
Do they take a bottle to bed at night? If so, what is in it?

Particularly important for young children

Trauma (additional questions to consider when assessing a child presenting with trauma)

When/Where/How/Anyone else involved?

Any other injuries? Were they unconscious? Do they feel nauseous?

Tetanus status

If avulsion – how long out for and what storage medium

Are all teeth/fragments accounted for?