Caries Risk Assessment Form
For Age > 6
Patient Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Contributing Conditions
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Fluoride Exposure
Sugary Foods or Drinks
Caries Experiences of Mother, Caregiver and/or other Siblings
Dental Home
General Health Conditions
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Special Health Care Needs
Chemo/Radiation
Eating Disorders
Medications that Reduce Salivary Flow
Drug/Alcohol Abuse
Clinical Conditions
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Cavitated or Non-Cavitated Carious Lesions or Restorations
Teeth Missing Due to Caries in past 36 months
Visible Plaque
Unusual Tooth Morphology that compromises oral hygiene
Interproximal Restorations - 1 or more
Exposed Root Surfaces
Restorations with Overhangs and/or Open Margins; Open Contacts with Food Impaction
Dental/Orthodontic Appliances
Severe Dry Mouth (Xerostomia)
Overall assessment of dental caries at risk:
Low
Moderate
High
Overall Comments
Dentist Name
First Name
Last Name
Dentist Signature
Clear
Submit
Should be Empty: