• Please tell us about your child

  • Today's Date
     - -
  • Sex
  • Child's Date of Birth
     - -
  • Is your child adopted?
  • Does the child know?

  • Dental History

  • Is this your child's first visit to the dentist?
  • Any unfavorable experiences in another dental office?
  • Are there any specific concerns about the child's mouth or teeth?
  • How many times per day are the child's teeth brushed
  • Are the child's teeth flossed daily?
  • Does an adult assist with brushing and flossing the child's teeth?
  • Is fluoride toothpaste used?
  • Does the child use any additional fluoride products?
  • Has the child had or does the child need orthodontic treatment?
  • Does the child currently nurse?
  • Does the child currently use a bottle or a sippy cup?
  • If yes, does the child have the bottle or sippy cup in bed?
  • Any TMJ pain or symptoms (clicking, popping, limited opening)?
  • Has the child had any injuries to the mouth or face?

  • 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?
  • Has the child ever been hospitalized?
  • Has the child ever had surgery?
  • Does the child have a syndrome or a genetic disorder?
  • Any congenital birth defects or craniofacial defects?
  • Any physical disabilities?
  • Is the child on the autistic spectrum?

  • 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

  • Does the child have any of the following breathing issues?

  • Asthma
  • Environmental Allergies
  • Snoring
  • Enlarged Tonsils/Adenoids
  • Sleep Apnea
  • Trouble Breathing Through
  • Format: (000) 000-0000.
  • Date
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