A child's dental health is effected by many different things. The three most impor-

tant to developing teeth are home care (toothbrushing, flossing and the use of

fluoride), any habits relating to the mouth or teeth, and your child's diet. To help us

better evaluate your child's dental health, please answer the following questions:

                                                        HABITS

Did/does your child suck his/her thumb or finger?   YES    NO
                Stopped at age _________     Still does ________ Only at night ________

Does your child chew ice?   YES   NO

Does your child grind his/her teeth?   YES   NO

Does your child have any other tooth related habits? ___________________________

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                                      HOME DENTAL CARE

Does your child brush his/her own teeth?   YES   NO
          How often? ______ times per day    ______ times per week

Do you brush your child's teeth?   YES   NO
          How often? ______ times per day    ______ times per week

How much toothpaste do you use? _________________________

Does your child swallow it?   YES   NO

Does your child use dental floss?   YES   NO
          If yes, how often? ______ times per day  ______ time per week

Do you floss your child's teeth?   YES   NO
          If yes, how often? ____ times per day ____ times per week ____ times per
 

Does your child take fluoride drops or tablets?   YES   NO
          If yes, at what age did he/she start taking them? _________________
          Is he/she still taking them?   YES   NO

Has you child ever lived in a fluoridated area?   YES   NO
          If yes, what age? ___________   How long? ____________

Does your child use a fluoride mouthwash?   YES   NO
          If yes, at school ________  at home ________  brand name _______________

Has your child received fluoride treatments at a dental office?   YES   NO

Anything else you would like to add about the care of your child's teeth at home?

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                                                   DIET

How many meals per day does your child eat? _______________

How many between meal snacks (including drinks other than water) does your child
         have on an average day? _____________________

Does your child chew gum with sugar in it?   YES   NO
          If yes, how often?  ______ times per day ______ times per week

Does your child have raisins, fruit rollups, fruit wrinkles, candy in small pieces,
          breath mints, or suckers?    YES   NO
          If yes, please circle the ones that are applicable.

Would you like to make any comments about your child's diet?

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