Toothbrushing Session Log Form
Log details of each toothbrushing session. All fields are designed for routine session tracking.
Date of Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Session
*
Hour Minutes
AM
PM
AM/PM Option
Duration (minutes)
*
Who Brushed?
*
Please Select
Self
Parent/Guardian
Caregiver
Other
Brushing Method
*
Please Select
Manual
Electric
Assisted
Other
Toothpaste Used
*
Please Select
Fluoride
Non-fluoride
Children's
Sensitive
Other
Areas Brushed
*
Upper Front
Upper Back
Lower Front
Lower Back
Tongue
Other
Flossing Performed?
*
Yes
No
Session Quality
*
Please Select
Excellent
Good
Fair
Poor
Notes or Observations
Submit Session Log
Should be Empty: