Infant Risk Assessment

 

______________________________________________

Please Complete and Print Out

Child's Name: Date:

Child's Age: Birth Date:


Health History

Did birthmother have any problems during pregnancy? Yes      No
Was child premature? Yes      No
Was child's birth weight low? Yes      No
Were there any complications at birth? Yes      No
Has your infant been ill? Yes      No
Is your child on any medications? Yes      No
 Notes: 

Diet and Nutrition

Is/was your child breastfed? Yes      No
Does your child sleep with a bottle? Yes      No
Does your child drink from a cup? Yes      No
Is your Child on a special diet? Yes      No
 Notes: 

Fluoride Adequacy

Do you know the fluoride level of your water? Yes      No
Do you have well water? Yes      No
If yes, has the water been tested? Yes      No
Do you use bottled water? Yes      No
Do you use a water conditioner or filtration system? Yes      No
Does your child take fluoride suppliments? Yes      No
 If yes, please list: 
Do you use a fluoridated toothpaste for your child? Yes      No
 Notes: 

Oral Habits
Does your child use a pacifier? Yes      No
Does your child suck a thumb or finger(s)? Yes      No
Does your child grind teeth day or night? Yes      No
 Notes: 

Injury Prevention/Trauma

Is your child walking? Yes      No
Is your home childproofed? Yes      No
Do you use a car seat for your child? Yes      No
Has your child had an oral/facial injury? Yes      No
 Notes: 

Oral Development

Does your child have any teeth? Yes      No
 Child's age (in months) when first tooth erupted: 
Has your child experienced teething problems? Yes      No
Have you noticed any oral problems in your child? Yes      No
 Notes: