Please tell us about your child
Child's Name
Nick Name
Today's Date
-
Month
-
Day
Year
Date
Sex
Male
Female
Child's Date of Birth
-
Month
-
Day
Year
Date
Child's Age
Attends What School:
Is your child adopted?
Yes
No
Does the child know?
Yes
No
Brother's Names & Ages
Sister's Names & Ages
Dental History
Is this your child's first visit to the dentist?
Yes
No
Any unfavorable experiences in another dental office?
Yes
No
Are there any specific concerns about the child's mouth or teeth?
Yes
No
Please describe further, if necessary:
How many times per day are the child's teeth brushed
0
1
2
3
Are the child's teeth flossed daily?
Yes
No
Does an adult assist with brushing and flossing the child's teeth?
Yes
No
Is fluoride toothpaste used?
Yes
No
Does the child use any additional fluoride products?
Rinse
Gel
Water
Tablets or Drops
Has the child had or does the child need orthodontic treatment?
Yes
No
Does the child currently nurse?
Yes
No
Does the child currently use a bottle or a sippy cup?
Yes
No
If yes, does the child have the bottle or sippy cup in bed?
Yes
No
Any TMJ pain or symptoms (clicking, popping, limited opening)?
Yes
No
Has the child had any injuries to the mouth or face?
Yes
No
If yes, please describe:
Does the child have any of the following habits?
Pacifier Use
Thumb or Finger Sucking
Lip Sucking or Licking
Grinds Teeth
Bites Nails
Tongue Thrust
Health History
Has the child ever had a serious illness?
Yes
No
If yes, please explain:
Has the child ever been hospitalized?
Yes
No
Has the child ever had surgery?
Yes
No
Does the child have a syndrome or a genetic disorder?
Yes
No
Any congenital birth defects or craniofacial defects?
Yes
No
Any physical disabilities?
Yes
No
Is the child on the autistic spectrum?
Yes
No
Has the child had a history of, or condition related to the following?
Congenital Heart Defect
Lung Disease
Kidney Disease
Liver Disease / Hepatitis
Endocrine System
Diabetes
GI Disease
Acid Reflux / GERD
Celiac or Irritable Bowel
Hemophilia / Bleeding Disorder
Blood Disorder
Cancer or Tumors
Leukemia
Developmental Delay
Speech Delay
Hyperactive / ADD
Sensory Integration
Vision Impairment
Hearing Impairment
Seizures or Epilepsy
Premature Birth
Cerebral Palsy
Skin Disorder
Please discuss any medical conditions further, if necessary:
Please list allergies (medications, foods, latex):
Please list any medications the child is taking:
Does the child have any of the following breathing issues?
Asthma
Environmental Allergies
Snoring
Enlarged Tonsils / Adenoids
Sleep Apnea
Trouble Breathing Through
Child's Physician
Phone Number:
Please enter a valid phone number.
Parent/Guardian Signature
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
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