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.
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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