• Texas Health Steps Oral Health Questionnaire

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • HEALTH HISTORY

  • Select Yes or No:*
    Rows

  • DIET AND NUTRITION

  • Select Yes or No:*
    Rows

  • FLUORIDE ADEQUACY

  • Select Yes or No:*
    Rows
  • Do you use a water conditioner or filtration system?*

  • ORAL HABITS

  • Select Yes or No:*
    Rows

  • INJURY PREVENTION

  • Select Yes or No:*
    Rows

  • ORAL DEVELOPMENT

  • Select Yes or No:*
    Rows

  • ORAL HYGIENE

  • Select Yes or No:*
    Rows

  • PRIVACY NOTIFICATION: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559 004) - First Dental Home

  • Texas Health Steps Dental Risk Assessment Questionnaire

  • Parents are caregivers -  use this form to tell us about your the oral health of your child. This will be part of your child's health record. 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Does your family drink water with fluoride in it or do your children take fluoride tablets?*
  • 2. Does your child use a toothpaste with fluoride in it?*
  • 3. Do you help your child with tooth brushing?*
  • 4. Have you or your children ever had a bad dental experience?*
  • 5. Have any of your children ever had cavities?*
  • 6. Does your child complain of mouth pain?*
  • 7. Does your child take a bottle to bed?*
  • 8. Does your child walk around drinking from a bottle or cup?*
  • 11. How is your own dental health?*
  • 12. Do you have any cavities?*
  • 13. Do your gums bleed? *

  • Did you know?

    For every 100 school children, more than 5 days of school per year are lost due to dental disease.

    Good dental health is important!

     

    PRIVACY NOTIFICATION: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021 , 552.023, 559.003 and 559.004)

  • Should be Empty: