3299 Clear Vista CT NE STE B,
Grand Rapids,
MI
49525
(616) 608-6826
HOME
DR. HAMILTON
DIRECTIONS
NEW PATIENTS
INSURANCE
CONTACT
TREATMENTS
GALLERY
PAY ONLINE
Dental and Fluoride History Form
Dental History
Child's Full Name
What is the reason for your today's dental visit?
Has your child ever been to the dentist?
Yes
No
Name of previous dentist
Date of Visit
Were x-rays taken?
Yes
No
Did your child have difficulty cooperating?
Yes
No
Explain
Does your child suck a finger, thumb or pacifier?
Yes
No
Was your child bottle fed?
Yes
No
If yes, weaned at what age
Was your child breast fed?
Yes
No
If yes, weaned at what age
Does your child go to bed with a bottle or sippy cup?
Yes
No
Do you assist your child's tooth brushing
Yes
No
When does your child brush?
upon rising
right after meals
after eating any food
before bed
Has your child's teeth ever been injured?
Yes
No
Which teeth?
Do you expect your child to be cooperative?
Yes
No
Does your child have any of the following issues?
cavities
toothache
mouth bleeding
sensitive teeth
trauma
gum infections
jaw sounds
other
Comments
Flouride History
Does your house have well water?
Yes
No
Has your well ever been tested for fluoride levels?
Yes
No
Does your child have any other forms of fluoride?
Yes
No
What kind?
ABOUT:
Dr. Hamilton
Gallery
Map & Directions
OFFICE INFO:
Contact
Insurance
Patient Forms
TREATMENTS:
Hygiene
Pediatric Dentistry
Special Needs Adults
Sedation
HIPAA FORMS:
Non-Discrimination Notice
Notice of Privacy Practices
Hamilton Pediatric Dentistry P.C. - Veronica Hamilton, DDS
3299 Clear Vista CT NE STE B
Grand Rapids
MI
49525
Phone:
(616) 608-6826