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Dental history

* indicates a required field
Is this your child’s first dental visit?
**If your child has previously visited a dentist, please answer the following:
Please indicate if your child has any of the following oral conditions:
Dental defects or anomalies *(required)
Mouth sores or fever blisters *(required)
Bad breath *(required)
Bleeding gums *(required)
Cavities *(required)
Toothache *(required)
Injury to mouth or teeth *(required)
Clenching or grinding teeth *(required)
Jaw joint problems (popping, pain, catching, etc) *(required)
Excessive gagging *(required)
Sucking habits (finger, thumb, pacifier) *(required)
Please answer the following questions regarding at-home oral care:
Does your child brush 1-2 times daily? *(required)
Is your child flossing? *(required)
Does someone help with brushing and flossing? *(required)
Does your child use fluoride toothpaste? *(required)
Is your child a picky eater? *(required)
Does your child like to snack throughout the day? *(required)
Does your child use a sippy cup or bottle? *(required)
Does your child take any drinks to bed? *(required)
Does your child participate in any sports? *(required)
Infants: Is your child still nursing?
Adolescents/Young Adults: Any history of recreational drug use?
Adolescents/Young Adults: Any current or previous oral piercings?