This form is designed for pregnant women to share information about themselves with dental office staff. It includes questions about prenatal care, what a woman does to take care of her mouth and teeth, and her experiences during pregnancy. The form is available in English and Spanish.
Pregnant women: Please fill out this form about yourself. The information you give will help the dental office staff understand and meet your needs. Bring it with you to your dental appointment.
My name:
My age:
I’m _________ weeks pregnant
My baby’s expected due date is:
My last dental visit was:
- 6 months ago
- 12 months ago
- more than 12 months ago
- I can’t remember
I’m receiving prenatal care: Yes | No
The name of my prenatal care provider and their office phone number are:
I do the following things to take care of my mouth and teeth:
I have the following questions about taking care of my mouth and teeth:
During my pregnancy, I’ve experienced the following things:
- Bad taste in my mouth
- Swollen and/or bleeding gums
- Gagging when brushing
- Loose teeth
- Morning sickness (nausea, vomiting, gastric reflux)
- Toothaches/pain/swollen face
- Other, please specify:
During this pregnancy, I:
- Smoke
- Vape
- Drink alcohol
During this pregnancy, I feel the best during these times of the day:
Read more:
Resource Type: Publication
National Centers: Health, Behavioral Health, and Safety
Audience: Families
Last Updated: May 11, 2023