A child's dental health is effected by many different things. The three most impor-

tant to developing teeth are home dental care (brushing, flossing and the use of

fluorides), any habits relating to the mouth or teeth, and your child's diet. To help

us better evaluate your child's dental health, please answer the following questions:


Did/does your child suck his/her thumb or finger?   YES   NO
        Stopped at age ________    Still does ________    Only at night ________

Does your child grind his/her teeth?   YES   NO

Does your child have any other tooth related habits? __________________________

                              HOME DENTAL CARE

Does your child brush his/her own teeth?   YES   NO
        How often?  ______ times per day   ______ times per week

Do you brush your child's teeth?   YES   NO
        How often?  ______ times per day   ______ times per week

How much toothpaste does your child use? _________________________

Does he/she swallow it?   YES   NO

Do you floss your child's teeth?   YES   NO
        How often?  ______ times per day  ______ times per week

Does/did your child take fluoride drops or tablets?   YES   NO
        If yes, at what age did he/she start taking them? __________________
        Is he/she still taking them?   YES   NO

Has your child ever lived in a fluoridated area?   YES   NO
        If yes, at what age? ________   How long? ________

Has your child received fluoride treatments at a dental office?   YES   NO

Anything else you would like to add about the care of your child's teeth at home?



Was/is your child put to bed with a bottle?   YES   NO
        If yes, what was in the bottle? _______________________________________

Was/is your child allowed to carry a bottle or cup throughout the day containing
        something other than plain water?   YES   NO

Does your child chew gum with sugar in it?   YES   NO
        If yes, how often? ______times per day ______times per week

How many meals per day does your child eat? ______________

How many between meal snacks including drinks other than water does your child
        have on an average day? ________________

If your child is using a pacifier, is it ever dipped in honey or other sweet substances?
        YES NO

Would you like to make any comments about your child's diet?



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