How to access the information on this page:
- Directly on this page
2. Dental Checklist to print as a hard copy
3. Dental Checklist to download on your device, making updates anytime
Date: ___________________ Court Entry given to current provider(s)
Child’s name: _______________________________________________ Date of birth: __________________
Provider’s name: ____________________________________________ Phone: _______________________
Address: _______________________________________________________________________________
Building Blocks Dental Assessment
Date: ______________ Time: _______________ Note yes or no to each section and add any comments. |
White, chalky spots on teeth? Comments:
|
Brown or gray spots on teeth? Comments:
|
Parts of teeth missing? Comments:
|
Toothbrushes & toothpaste in home? Comments: |
Suck thumb/use pacifer? Comments: |
Go to bed with bottle/sippy cup? Comments: |
Caregiver’s oral hygiene? Comments: |
Question for caregiver: what are you doing to care for the child’s teeth? |
updated 10.6.17