Appendix A

Intake Form for Patients with Autism

Patient Name:

Phone number:

Date of Birth:


Individual filling out form:


Describe the nature of your child’s disability:

Please list all medications both prescription and over-the-counter that the patient is taking.

Has your child ever had seizures?

If so, when was the last one?

Describe the type of seizure.

Does your child have any allergies?

Does your child breathe through their nose or mouth?

Does your child snore?

Does your child wear a hearing aid?

Does your child have any other physical challenges the dental team should be aware of?

Is your child on a special diet? (Gluten free, casein free)


Has your child been to the dentist before?

How did the visit go?

Tell us about how you take care of the child’s mouth at home. How often do you brush? Does the child allow you to brush? To floss? Are they able to rinse and spit?

Tell us about the child’s diet. What type of foods do they like? How often do they snack throughout the day? Is he/she a picky eater? If so what types of foods do they prefer?

Is your child’s mouth in pain or discomfort now? Does he/she communicate pain/discomfort to you?

Does your child grind or clench their teeth? When do they clench/grind? Night/day, both?

Does your child drool?

Does your child suck their thumb or fingers? Do they chew or suck on non-nutritive items (toys, rocks etc)


Is your child able to communicate verbally?

Does your child use some form of alternative communication like the iPad or pictures?

Are there certain cues the child does that would be helpful for the dental team to know? (i.e. flap hands when frustrated)

Will you bring a communication device with you to the appointment?

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

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

How do you reward your child at home? What rewards does the child find highly motivating?

What is your child’s favorite movie/toy/character?


Please list any specific sounds that your child is sensitive to.

Does your child prefer a dimly lit room?

Does your child prefer quiet?

Is your child sensitive to motion and moving (moving the dental chair from sitting to reclining)

Do certain tastes bother your child? Please list.