Dental and Fluoride History Form

Dental History
Child's Name:
What is the reason for your today's dental visit?
Has your child ever been to the dentist?	Yes No
Name of previous dentist:
Date of visit:
Were x-rays taken?	Yes No
Did your child have difficulty cooperating?	Yes No
Explain:
Does your child suck a finger, thumb, or pacifier?	Yes No
Was your child bottle fed?	Yes No
Was your child breast fed?	Yes No
What age were they weaned?
Does your child go to bed with a bottle or sippy cup?	Yes No
What is in the sippy cup?
Do you assist your child's tooth brushing?	Yes No
When does your child brush?	Upon rising Right after meals After eating any food Before bed
Has your child's teeth ever been injured? Which teeth?
Do you expect your child to be cooperative?	Yes No
Does your child have any of the following issues?	Cavities Toothache Sensitive Teeth Mouth Breathing Trauma Gum Infections Jaw Sounds Other
Comments:

Fluoride History
Does your house have well water?	Yes No
Has your well ever been tested for fluoride levels?	Yes No
Does your child use fluoridated toothpaste?	Yes No
Do you give your child any other forms of fluoride?	Yes No
What?