Dental History- Child (Short)

This form is a short version of the Child Dental History form that collects information regarding a minor patient's dental history, oral health, oral hygiene habits, and previous dental treatments. 

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Dental History Child

Date of last dental visit ______________________
What service did your child receive? ______________________
Has your child complained about dental problems? ________No/Yes________
Does your child brush his or her teeth daily? ________No/Yes________
Does your child floss his or her teeth daily? ________No/Yes________
Does your child grind his or her teeth? ________No/Yes________
Is fluoride taken in any form (including water supply)? ________No/Yes________
Has your child had any mouth, teeth, or head injuries? ________No/Yes________
Has your child had any unhappy dental experiences? ________No/Yes________
Does your child have any mouth habits (i.e. thumbsucking,nail biting, mouth breathing, pacifier, sleeping with bottle)? ________No/Yes________ 
If you would like to explain any of these answers, please do so here:  

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x_______________________________                    Date:____________________________

Please Sign Here (Patient)

 
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