Child Oral Health Survey Form
Please complete this survey to help us better understand your child's oral health habits and needs.
Child's Age Group
*
Please Select
Under 3 years
3-5 years
6-9 years
10-12 years
How often does your child brush their teeth?
*
Twice a day or more
Once a day
A few times a week
Rarely/Never
How often does your child floss?
*
Daily
A few times a week
Rarely/Never
When was your child's last dental visit?
*
Within the past 6 months
6-12 months ago
More than 1 year ago
Never
How often does your child consume sugary snacks or drinks?
*
Multiple times a day
Once a day
A few times a week
Rarely/Never
Who usually supervises your child's tooth brushing?
*
Parent or guardian
Older sibling
Child brushes alone
How would you rate your child's overall oral health?
*
1
2
3
4
5
Has your child experienced any of the following in the past 6 months?
*
Tooth pain
Bleeding gums
Cavities
Difficulty chewing
None of the above
How often does your child rinse their mouth after eating?
*
Always
Sometimes
Rarely/Never
Do you have any additional comments or concerns about your child's oral health?
Submit Survey
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