Pediatric Dental Questionnaire Ages 2-6 years

Patient Name:

Date of Birth:

Age of your child

Individual completing form:

Relationship:

Has your child been seen by a dentist?

YES NO

If yes, who does your child see?

How often does your child go for dental exams?

Twice A Year Once A Year Not At All

Does your child brush their teeth daily, with or without assistance?

Yes, daily without assistance Yes, daily with assistance Yes, daily occasionally with assistance No, not daily without assistance No, even with assistance Other:

If other, specify:

If you have well water at home, does your child take Fluoride Supplements?

YES NO

If your child is under 4 years of age, does he or she still drink from a bottle?

YES NO

If your child is under 4 years of age, does he or she still use a pacifier?

YES NO

Does your child drink anything after going to bed other than water?

YES NO

If yes, what does your child drink?

Does your child seem to snack often, especially sugary snacks or drinks?

YES NO

Has your child already been seen for soft enamel or cavities?

YES NO

Has your child had fluoride treatments at a dentist office?

YES NO

Has your child had dental sealants applied?

YES NO

If yes when?

Does your child wear braces, a retainer or expander?

YES NO

Has your child ever had any tooth extractions?

YES NO

Has your child experienced any dental injury?

YES NO

If yes, please explain:

Does your child experience any tooth pain, gum or mouth pain or bleeding?

YES NO

Would you like our advice or assistance in finding a dentist or would you like additional dental care information?

YES NO

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