Dental Care (Birth to Age 5)

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