Dental History

Is this your child's first visit to the dentist?

Yes No

Does your child have any dental problems are cavities you are aware of?

Yes No

If yes, please explain:

Has your child had any injuries to the teeth, face or mouth?

Yes No

If yes, please explain:

Does your child use a mouth guard for sports?

Yes No

If yes, what sports?

Has your child ever had a negative experience or problem associated with previous dental visits?

Yes No

If yes, please explain:

Please check any of the habits your child has/had:

Was/Is your child breast or bottle fed?

Yes No

If yes, to what age were they breast or bottle fed?

Does your child sleep or nap with a bottle or feed throughout the night?

Yes No

Does your child drink milk, juice, pop or soda on a regular basis or throughout the day?

Yes No

Does your child drink fluoridated tap water?

Yes No

Has your child ever taken a PRESCRIPTION fluoride supplement?

Yes No

If yes, what was the supplement?

Does your child use a flouride toothpaste?

Yes No

How often are your child's teeth brushed?

How often are your child's teeth flossed?

Who brushes and flosses your child's teeth?

Digital Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status.

Hours

Meredith Kurysh, DDS