Infant Visit Form
Baby Oral Health Program (BOHP)
Child's Full Name
*
First Name
Last Name
Name child goes by:
*
Select one:
*
Male
Female
Date of Birth:
*
/
Month
/
Day
Year
Date
Age
*
Address
*
City/State:
*
Zip:
*
Home Number:
Cell Phone Number
*
Please list any other siblings seen in this office:
How did you hear about us?
*
Please Select
Website
Google
Doctor Office
Friend
Event
Social Media
Building Sign
Preschool Visit
Other
Who may we thank for referring you to us?
Parent/LG Name
*
Relationship to Patient:
*
Primary Email:
*
example@example.com
Primary Dental Insurance:
Physician/Phone #
Did you have any complications during your pregnancy?
Is your child under the care of a physician for any illness?
*
Yes
No
Is your child taking any medications? Please list
Is your child up to date on all current immunizations?
Yes
No
Is your child allergic to any drugs or Latex products?
Yes
No
If yes, please list.
Has your child ever had any health concerns?
Anything else you would like to tell us about your child?
Feeding Practices
Yes
No
Breast Fed
Bottle Fed
Sippy cup use
Sleeping with something other than water
>4-6 oz juice/day
Soda use
Frequency of snacking >3 times/day
If breast fed, until what age?
If bottle fed, until what age?
Oral Hygiene Practices
Yes
No
Started cleaning teeth
Difficulty cleaning teeth
Started Flossing
Fluoride toothpaste
Fluoride Exposure
City
Well
Bottled
Source of drinking water at home
Yes
No
Child stays outside home during the day
Fluoride supplements prescribed
Oral Habits
Yes
No
Finger/thumb/pacifier
If yes, is anything associated with habit?
If something associated with habit, please list. (e.g. blanket, teddy bear, etc.)
Yes
No
Problems with teeth noted
Injury Prevention
Yes
No
History of dental trauma
Family History of Dental Problems:
Parent/Guardian Signature:
*
Clear
Date
/
Month
/
Day
Year
Date
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