Pediatric First Visit Medical/dental History Form Page 2
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1
2
3Dental History
What is your primary concern about your child’s oral health?____________________________________________________________________
What was your child’s age in months when the first tooth appeared? _____________
Which of the following do you use to clean your child’s teeth?
Toothbrush
Washcloth
Floss
Fluoride Toothpaste
Fluoride-Free Toothpaste
Other_____________
How often do you brush your child’s teeth? ________ times per __________
How often do you floss your child’s teeth? ________ times per __________
Who cleans your child’s teeth?
Parent
Child
Caregiver
Other: _______________
What does your child drink out of? __________________________________
Who takes care of your child? Circle all that apply:
Mother
Father
Grandparent
Sibling(s)
Daycare
Nanny
Babysitter
Other
Have any of the following had cavities in the past year? Circle any that apply:
Mother
Father
Grandparent
Sibling(s)
Frequent Caregiver
Are you eligible for any of the following government programs?
WIC
Head Start
Medicaid
SCHIP
If you could wave a magic wand and have one wish granted for your child’s oral health, what would it be:
________________________________________________________________________________________________________________________
YES NO Does your child take fluoride supplements?
YES NO Does your child nap or sleep with a bottle? Contents:___________________
YES NO Was your child breast-fed? How long? ________________________________
Does your child currently have or have they ever had any of the following:
YES NO Dental exam
Approximate date? _________________________
YES NO Dental xrays
YES NO Dental treatment? Describe: ________________________________________________
YES NO Injury to face or jaw
YES NO Lumps or sores inside the mouth
YES NO Cold sores or canker sores
Location:___________
How many times/year?_________________
YES NO Bleeding gums
YES NO Grinding or gritting of teeth
YES NO Jaw joint pain
YES NO Sucking habit beyond 1 year of age
Dietary Evaluation:
How frequently does your child consume the following types of foods/drinks?
(If possible, please provide specifics on the type of foods/drinks your child is most commonly consuming)
FOOD/DRINK
# TIMES/DAY
TYPE
Candy
Snacks between
meals
Vegetables
Fruit
Chewing gum
Milk
Water
Soft Drinks*
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