• Oral Health Questionnaire

    (for Ages 2 and under)

  • 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.

  • Date*
     - -

  • Health History

  • Did the birth mother have any problems during pregnancy?
  • Was your child premature?
  • Was your child’s birth weight low?
  • Were there any complications at birth?
  • Has your child been ill?
  • Is your child on any medications?

  • Diet And Nutrition

  • Is/was your child breastfed?
  • Does your child sleep with a bottle?
  • Does your child drink from a cup?
  • Does your child walk around drinking from a bottle or cup?
  • Is your child on a special diet?

  • Fluoride Adequacy

  • Do you know the fluoride level of your water?
  • Do you have well water?
  • Do you use bottled water?
  • Do you use a water conditioner or filtration system?
  • Do you use fluoride toothpaste for your child?

  • Oral Habits

  • Does your child use a pacifier?
  • Does your child suck a thumb or fingers?
  • Does your child grind his/her teeth day or night?

  • Injury Prevention

  • Is your child walking?
  • Is your home childproofed?
  • Do you use a car seat for your child?
  • Has your child had an injury to his/her mouth or face?

  • Oral Development

  • Does your child have any teeth?
  • Has your child had teething problems?
  • Have you noticed any problems with your child’s mouth or teeth?
  • Does your child complain of mouth pain?
  • Have any of your children ever had cavities?
  • Have you or your children ever had a bad dental experience?

  • Oral Hygiene

  • Do you clean your child’s gums/teeth?
  • Do you use a toothbrush to clean your child’s teeth?
  • Do you use toothpaste to clean your child’s teeth?

  • 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)

  • Should be Empty: