Dental History- Child

 

This form collects information regarding a minor patient's dental history, oral health, oral hygiene habits, dietary habits, physical activity, and previous dental treatments.

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Dental History Child

What is your primary concern about your child's oral health?  
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How would you describe your child's oral health?  
Excellent/ Good/ Fair/ Poor
How would you describe your oral health?  
 Excellent/ Good/ Fair/ Poor
How would you describe the oral health of your other children?  
 Excellent/ Good/ Fair/ Poor
Is there a family history of cavities?  
   ________No/Yes________

Please indicate if your child has a history of any of the following:

 
Inherited dental characteristics ________No/Yes________
Mouth sores or fever blisters ________No/Yes________
Bad breath ________No/Yes________
Bleeding gums ________No/Yes________
Cavities/decayed teeth ________No/Yes________
Toothache ________No/Yes________
Injury to teeth, mouth or jaws ________No/Yes________
Clinching/grinding his/her teeth ________No/Yes________
Jaw joint problems (popping, etc.) ________No/Yes________
Excessive gagging    ________No/Yes________
Sucking habit one year of age  ________No/Yes________
   
Brushing and Flossing  
How often does your child brush his/her teeth?  
Never/ Occasionally/ Once a day/ Twice a day/ Three times a day/ Every time I eat
Does someone help your child brush?  
  ________No/Yes________
How often does your child floss his/her teeth?  
Never/ Occasionally/ Once a day/ Twice a day/ Three times a day/ Every time he/she eats
Does someone help your child floss?   
  ________No/Yes________
What type of toothbrush does your child use?   
Hard/ Medium/ Soft/ Unsure
What toothpaste does your child use?     
  ________________________
Water and Fluoride  
Do you use a water filter at home?  ________No/Yes________
   
Please check all sources of fluoride your child receives:  

[x] Fluoride treatment in the dental office [x] Fluoride varnish by pediatrician/ other practitioner [x] Prescription drops/ tablets/ vitamins
[x] Drinking water [x] Toothpaste [x] Over-the-counter rinse
[x] Prescription rinse/gel [x] None [x] Other
   
Dietary Habits  
Does your child regularly eat 3 meals each day?  ________No/Yes________
Is your child on a special or restricted diet? ________No/Yes________
Is your child a 'picky eater'? ________No/Yes________
Does your child have a diet high in sugars or starches? ________No/Yes________
Do you have any concerns regarding your child's weight? ________No/Yes________
   
Please select how frequently your child has the following:  
Candy or other sweets  
  Rarely/ 1-2 times/day/ 3 or more times/day
Chewing gum        
  Rarely/ 1-2 times/day/ 3 or more times/day
Snacks between meals   
  Rarely/ 1-2 times/day/ 3 or more times/day
Soft drinks  
Rarely/ 1-2 times/day/ 3 or more times/day
Please note other significant dietary habits  
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Sports and Activities  
Does your child participate in any sport or similar activities? ________No/Yes________
Does your child wear a mouthguard during these activities? ________No/Yes________
   
 Previous Dental Treatment  
 Has your child been examined or treated by another dentist? ________No/Yes________ 
 Were x-rays taken of the teeth or jaws? ________No/Yes________ 
 Has your child ever had orthodontic treatment (braces, spacers, or other appliances)?  ________No/Yes________ 
Has your child ever had a difficult dental appointment? ________No/Yes________ 
 How do you expect your child will respond to dental treatment?  
  Very well/ Fairly well/ Somewhat poorly/ Very poorly
 Is there anything else we should know before treating your child?  

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x_______________________________                    Date:____________________________

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