Pediatric Dentistry Intake Form

The Pediatric Dentistry Intake Form is purpose-built for pediatric dental practices, capturing the child-specific oral health history that pediatric dentists need for age-appropriate evaluation and treatment planning. This template collects child demographics and parent/guardian information alongside a comprehensive pediatric dental assessment including eruption and exfoliation history, prior dental experience and treatment (positive and negative), dental anxiety level using a child-appropriate scale, oral habits (thumb sucking, pacifier use, tongue thrusting, bruxism), bottle and sippy cup use history, fluoride exposure (water supply, toothpaste, supplements), and dietary habits with attention to cariogenic foods and beverages.

Designed for pediatric dental practices, children's dental clinics, community dental health programs, and orthodontic offices evaluating pediatric patients, this form includes sections for the child's medical history with focus on conditions affecting dental care (bleeding disorders, heart conditions, seizure disorders, developmental disabilities, medication-induced gingival changes), allergy documentation with emphasis on latex and antibiotic allergies, behavioral considerations and special needs accommodations, prior sedation or general anesthesia history for dental procedures, immunization status, birth and neonatal history relevant to dental development (premature birth, NICU stay, cleft lip/palate), and family dental health history including parental caries experience.

All fields are HIPAA-compliant and designed with clear, parent-friendly language that makes the form easy to complete. The dental anxiety assessment and behavioral history sections help the dental team prepare behavior management strategies before the child arrives, leading to a more positive dental experience. The dietary and oral hygiene habit sections provide the foundation for anticipatory guidance and preventive counseling that is central to pediatric dental practice.