Pediatric Oral Exam Form
Please complete this form to provide information for your child's dental examination.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Medical History (e.g., allergies, current medications, medical conditions)
*
Dental History (e.g., previous dental visits, past treatments, dental concerns)
*
Chief Complaint or Reason for Visit
*
Oral Hygiene Assessment
*
Excellent
Good
Fair
Poor
Clinical Findings
*
Rows
Normal
Abnormal
Not Examined
Teeth
1
2
3
Gums
4
5
6
Bite (Occlusion)
7
8
9
Soft Tissues
10
11
12
Risk Factors / Habits
Thumb sucking
Pacifier use
Bottle feeding at night
High sugar diet
Other
Dentist's Recommendations / Treatment Plan
Parent/Guardian Signature
*
Submit Exam Form
Submit Exam Form
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