Conroe: Dental Risk Assessment Questionnaire - Element Dental And Orthodontics

Parents and caregivers – use this form to tell us about the oral health of your child. This will be part of your child’s health record.

Parent/Guardian Name

Date

Child's First Name

Child's Last Name

Child's Age

Does your family drink water with fluoride in it or do your children take fluoride tablets?

Does your child use a toothpaste with fluoride in it?

Do you help your child with toothbrushing?

Have you or your children ever had a bad dental experience?

Have any of your children ever had cavities?

Does your child complain of mouth pain?

Does your child take a bottle to bed?

Does your child walk around drinking from a bottle or cup?

How many times does your child eat a snack each day?

How many bottles does your child have each day

How is your own dental health?

Do you have any cavities?

Do your gums bleed?

Did you know?
For every 100 school children, more than 5 days of school per year are lost due to dental disease.
Good dental health is important!

PRIVACY NOTIFICATION: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification.
(Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004

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