This form is designed for parents to share information about their child with dental office staff to help them meet the child's needs. It includes questions about what makes a child smile or feel good, what may motivate the child to behave, and what to do when the child becomes shy, scared, or unsure during their dental visit. The form is available in English and Spanish.
Parents: Please fill out this form about your child. The information you give will help the dental office staff understand and meet your child’s needs. Bring it with you to your child’s dental appointment.
My name:
My nickname:
My age:
Name(s) of my parent(s):
When I’m at home, I speak (for example, English, Spanish):
When I’m not with my parents, these people take care of me:
- Grandparent
- Brother or sister
- Other relative
- Babysitter
- Head Start program
- Child care program
- Other
This is my first time at a dental office: Yes | No
I expect this visit to be (for example, fun, a little scary):
Things that make me smile or feel good are (for example, toys, games, phrases):
My favorite foods and drinks are:
When I behave well, I like to get (for example, a smile, a hug, praise):
The best way to help me when I’m feeling shy, scared, or unsure is to (for example, hold my hand, give me a hug, tell me I’m doing a good job):
My family has questions about helping me take good care of my mouth and teeth. Their questions are:
Read more:
Resource Type: Publication
National Centers: Health, Behavioral Health, and Safety
Audience: Families
Last Updated: August 30, 2024