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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