Medical History and Caries Risk Assessment

Demographic Information

Nick Name:
Home Phone:
Cell Phone:
Guardian Email:
Home Address:
Siblings we treat:
Parent/Legal Guardian:
Relation to patient:
Parent/Legal Guardian:
Relation to patient:
Who has legal custody:
Dental Insurance:
Whom may we thank for referring you to us?
What is the reason for your child's dental visit?
Child's Physician/Group:
Child's Physician City/St:
Child's Physician Phone#:

Health History

Date of last phyical exam:
Is your child in good health? Yes No
Is your child being treated by a physician at this time? Yes No
Has your child ever had a health problem? Yes No
Has your child ever been hospitalized? Yes No
Please give reason and dates:
Is your child allergic to anything including medications? Yes No
Is your child currently taking any medications? Yes No
Please give medication, dose and reason:
Has your child ever had a reaction to or problem with anesthetics? Yes No
Were there any problems before or at birth? Yes No
Is your child up to date on immunizations against childhood disease? Yes No

Dental History

Has your child ever been to the dentist? Yes No
Date of last xrays (if taken):
Name of dentist and date:
Has your child experienced any unfavorable reaction from previous dental care? Yes No
Does your child suck a finger, thumb or pacifier? Yes No
Does your child have pain with chewing, yawning, or wide opening? Yes No
Does your child's jaw make noise and is pain associated with the sounds? Yes No
Please check if your child is having problems with any of the following:
Gum Infections
Jaw Sounds
Sensitive Teeth
Color of teeth
Please check if your child has been treated for any of the following:
Abuse (mental, physical, emotional, sexual)
Frequent cough/cold
Adverse drug reactions
Behavioral problems
Personality/Social Disorder
Mental Delay
Physical Delay
Bladder or Kidney Problems
Blood Disorders (anemia, sickle cell)
Hemophilia, bruising easy, excessive bleed
Bone, Muscle, Joint Problems
Cleft Lip / Palate
Congenital Heart Defect/Disease
Congenital Birth Defects
Cystic Fibrosis
Cerebral Palsy
Developmental Disorders
Dietary Restrictions
Epilepsy / Seizures
Frequent Infections
Headaches (frequent/recurrent)
Hormonal Problems
Hydrocephaly or placement of a shunt
Jaundice, Hepatitis or Liver Problems
Sexually Transmitted Diseases
Skin Problems (hives, rash)
Speech/Hearing/Vision Problems
Stomach or Intestinal Problems
Thyroid or Pituitary Problems
Other (please specify)
Provide Details Here:
Is there any other significant medical history pertaining to this child or his/her family? Yes No
If Yes, describe:
Do you consider your child to be advanced in the learning process
progressing normally
slow in the learning process
Was your child breast fed
bottle fed
at what age was it stopped?

Fluoride History

Is your home water supply fluoridated? Yes No
Does your child use fluoride toothpaste? Yes No
Do you give your child any other form of fluoride? Yes No What?
Does your child participate in a school fluoride rinse program? Yes No

Consent for Dental Treatment

I request and authorize Dr. Snyder to examine, clean, and provide dental treatment on my child's teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Snyder to diagnose and/or treat my child's dental problem. I will allow photographs to be taken of my child or child's teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Snyder will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. I will be responsible for any charges incurred on this child for dental treatment.
Digital Signature:
Please take a few moments to answer these questions about your child's oral and dental health. By providing accurate information, it allows us as dental health care professionals to identify your child's individual risk for developing cavities and create a home care plan to better prevent cavities from developing and maintain a beautiful smile!

Dental History

Providing an accurate dental history is an important part of our exam. Please check the following that apply to your child:

Previous Dental Visits

this is patient's first visit to dentist
patient has previously seen a dentist for check-ups &/or treatment (fillings, etc)
patient was previously seen by a dentist and referred to Riverbend Pediatric Dentistry for care

History of Cavities

patient has no previous history of dental cavities
patient has a history of dental cavities
no family history of cavities
family history of caries - parents have active cavities
family history of caries - parents have history of cavities
family history of caries - siblings have active cavities
family history of caries - siblings have history of cavities

Home Care / Fluoride Exposure

patient receives adequate home care, brushing teeth at least twice per day with fluoride toothpaste
patient receives less than recommended daily oral care
patient's teeth are flossed on a regular basis
patient's teeth are not flossed on a regular basis
patient spends most of their time in an environment with adequately fluoridated water
patient spends most of their time in an environment that does not have adequately fluoridated water


patient's diet exposes them to a minimal amount of sugar
patient's diet exposes them to a moderate amount of sugar
patient's diet exposes them to a high amount of sugar
patient drinks predominantly low sugar drinks (mainly water)
patient has heavy intake of sugary drinks

Oral Habits

no oral habits present
oral habit present - finger habit
oral habit present - pacifier habit

Caries Risk Assessment

The following questions are taken from the American Academy of Pediatric Dentistry & the American Dental Association's tools that help to identify individual risk factors for developing dental cavities. More accurate answers ensure that we can provide the necessary recommendations for adequate preventive measures. Please check those biological and protective factors that apply to your child.

Biological Factors

Mother/primary caregiver has active cavities
Parent/caregiver has low socioeconomic status
Child has >3 between meal sugar-containing snacks or beverages per day
Child is put to bed with a bottle containing natural or added sugar
Child has special health care needs
Child is a recent immigrant

Protective Factors

Child receives optimally fluoridated drinking water
Child has teeth brushed daily with fluoride toothpaste
Child receives topical fluoride from health professional
Child has dental home/regular dental care