PEDIATRIC DENTAL HISTORY INFORMATION Date: Child Name (Last, First, MI): Birth Date %PatientNameLast%, %PatientNameFirst% %PatientNameMiddle% (MM/DD/YYYY) Prior Dentist / Dental Clinic Name: City / State: Last Dental Exam: Last Dental XRay: What is the primary reason for your child's visit today? SELECT THE APPROPRIATE ANSWER Is your child having any pain or discomfort at this time? Yes No Does your child feel nervous about having dental treatment? Yes No Has your child ever had a bad experience in a dental office? Yes No Has your child had an injury to the mouth, teeth or jaw? Yes No Does your child brush his/her teeth daily? Yes No Do you assist your child with brushing? Yes No Does your child use dental floss? Yes No Is your drinking water fluoridated? Yes No Do you give your child any other form of fluoride? Yes No Has your child ever had any of the following? (Please check all that apply) Dental Cavities Toothaches Abscesses (gum boils) Cold Sores Stained Teeth Bad Breath Does (or did) your child have habits that might affect oral health? (Please check all that apply) Clenching or Grinding Teeth Finger or Thumb Habits Pacifier Mouth Breathing Other