PEDIATRIC DENTAL HISTORY
Did birth mother have any health problems during pregnancy?
Has your child needed frequent use of liquid medication?
Are all of your child's immunizations up to date?
Has your child been diagnosed with any illness?
Please list any medications your child is taking and reason:
Please list any surgeries your child has had, reason and dates:
Is your child allergic to any medications?
If yes, please list:
Does your child suffer from any other allergies?
If yes, please list:
DIET AND NUTRITION
Is/was your child breastfed?
Is your child on a special diet?
Describe:
Does your child have difficulty swallowing?
How many times does your child eat a snack each day:
FLUORIDE ADEQUACY
Do you have well water?
If yes, has the water been tested for fluoride content?
Test results:
ORAL HABITS
Does your child have any oral habits?
Explain:
ORAL DEVELOPMENT
Do your child's teeth seem crooked or misaligned?
ORAL HYGIENE
How often does your child brush his/her teeth?
Does your child use a manual or electric toothbrush?
BEHAVIOR
Is this your child's first visit to the dentist?
How do you think your child will act towards the dentist?
Describe:
SLEEP BEHAVIOR
Does your child have difficulty sleeping?
Does your child experience nightmares?
What position does your child normally sleep in?
Does your child have trouble breathing or struggles to breathe?
Does your child have a tendency to sleep with their mouth open?
Do you notice if your child snores or makes other noises?
Does your child breathe through their mouth during the day?
DEVELOPMENT
Has your child been growing at a normal rate since birth?
Is your child overweight?
Does your child have frequent colds?
Does your child have allergies?
Has your child been diagnosed with ADD/ADHD?
PLEASE INDICATE YOUR RELATIONSHIP TO THIS CHILD
Date: 
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