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Our Office
Dr. Juntgen
Services
New Patients
317-846-5893
317-846-5893
Bill Pay
Appointments
Dental history
*
indicates a required field
Patient's Name *
(required)
Is this your child’s first dental visit?
Yes
No
**If your child has previously visited a dentist, please answer the following:
Name/Number of Previous Dentist
Date/Reason for Last Visit
Date/Reason for Last X-Rays
Please indicate if your child has any of the following oral conditions:
Dental defects or anomalies *
(required)
Yes
No
Mouth sores or fever blisters *
(required)
Yes
No
Bad breath *
(required)
Yes
No
Bleeding gums *
(required)
Yes
No
Cavities *
(required)
Yes
No
Toothache *
(required)
Yes
No
Injury to mouth or teeth *
(required)
Yes
No
Clenching or grinding teeth *
(required)
Yes
No
Jaw joint problems (popping, pain, catching, etc) *
(required)
Yes
No
Excessive gagging *
(required)
Yes
No
Sucking habits (finger, thumb, pacifier) *
(required)
Yes
No
Please answer the following questions regarding at-home oral care:
Does your child brush 1-2 times daily? *
(required)
Yes
No
Is your child flossing? *
(required)
Yes
No
Does someone help with brushing and flossing? *
(required)
Yes
No
Does your child use fluoride toothpaste? *
(required)
Yes
No
Is your child a picky eater? *
(required)
Yes
No
Does your child like to snack throughout the day? *
(required)
Yes
No
Does your child use a sippy cup or bottle? *
(required)
Yes
No
Does your child take any drinks to bed? *
(required)
Yes
No
Does your child participate in any sports? *
(required)
Yes
No
Infants: Is your child still nursing?
Yes
No
Adolescents/Young Adults: Any history of recreational drug use?
Yes
No
Adolescents/Young Adults: Any current or previous oral piercings?
Yes
No