Dental History- Child

Tyler Regas
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: |
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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: | ||||||||||
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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 | ||||||||||
_____________________________________________________________________________________ | ||||||||||
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:____________________________ Please Sign Here (Patient) |
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