Child's Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please help us treat your child more completely by answering these questions
Did your child:
Have Reflux
Yes
No
Bottle or breast feeding past 1 year old
Yes
No
Difficutly with Nursing
Yes
No
Thumb/Finger sucking
Yes
No
Pacifier use older than 2 years
Yes
No
Use a sippy cup past 2 years old
Yes
No
Have Asthma
Yes
No
Take a drink to bed with them
Yes
No
Please give details if you answered yes to any of the above:
Is your house water from a well or use a reverse osmosis water purifier?
Is there a family history of dental cavities (mom, dad, or siblings)?
Does your child use a fluoride toothpaste?
Do you help your child brush and floss?
Do you have any concerns about your child's diet? If yes, please explain.
Please check any snacks and drinks that you child has more than twice a week:
Chocolate/Strawberry milk
Fruit Snacks/dried fruits
Juice or gatorade/sports drinks
Hard Candies/suckers
Soda
Sticky Candies (skittles, Laffy Taffy, Caramels)
Flavored Water
Would you consider your child to be a frequent snacker?
Is there anything about your child's development that we need to know:
Hearing
Extremely Fearful
Autism
Gags when brushing
Eyesight
Heart Murmur
ADD
Developmental delayed
Sensitive to vibrations or sounds
ADHD
Other
Please explain:
Is there anything that you would like the Hygienist or Doctor to address today?
Preview PDF
Submit
Should be Empty: