Outreach Oral Health Care

Bright Smiles Baby Programme

Risk Assessment Form

About the Bright Smiles Baby Programme

You may participate in this programme by completing the risk assessment form below.

For enquiries, please contact Oral Health Promotion Division at 2199 9253 during office hours. Our office hours are Monday to Friday, 9:00 a.m. to 1:00 p.m. and 2:00 p.m. to 5:30 p.m. (public holidays excluded).

Personal and Child Particulars

Date of Birth of Child *:

Name of Parent / Guardian *:

Relationship *:

Father or Mother

Grandparent

Others, please specify *:

English Surname of Child:

English Given name of Child:

Chinese Name of Child:

Child's Gender *:

Male

Female

Document Type *:

Document Number *:

Contact Phone Number of Parent / Guardian *:

Email Address *:

6-8 Months Child

Q1. Are there anyone (including yourself) brushing your child's teeth? *

Yes

Tooth not yet erupt

Q2. If we provide free oral examination services for your children within the next year, would you be willing to accept it? *

Yes, Preferred District *:

9-36 Months Child

Q1. Has there been someone (including yourself) brushing your child's teeth? *

Yes

Q2. If we provide free oral examination services for your children within the next year, would you be willing to accept it? *

Yes, Preferred District *:

Q3. Does your child take milk by milk bottle? *

Yes

Q4. Does your child intake any food/milk after toothbrushing or before bedtime? *

Yes

Q5. Is breast milk included in the child's meals? *

Yes

Q6. How many times did your child intake sugar/chocolate daily during past two weeks? *

Less than once

Once or more

Outreach Oral Health Care and Promotion Programme

Bright Smiles Baby Programme