This form collects information regarding a minor patient's dental history, oral health, oral hygiene habits, dietary habits, physical activity, and previous dental treatments.
| ___________________________________________________________________________________________________ |
Dental History Child
| What is your primary concern about your child's oral health? | ||||||||||
| _____________________________________________________________________________________ | ||||||||||
| 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________ | ||||||||||
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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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_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ |
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x_______________________________ Date:____________________________ Please Sign Here (Patient) |
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| ____________________________________________________________________________________________________ |
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