Caries Risk Assessment Form
For Age > 6
Patient Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contributing Conditions
Rows
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Fluoride Exposure
1
2
3
Sugary Foods or Drinks
4
5
6
Caries Experiences of Mother, Caregiver and/or other Siblings
7
8
9
Dental Home
10
11
12
General Health Conditions
Rows
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Special Health Care Needs
13
14
15
Chemo/Radiation
16
17
18
Eating Disorders
19
20
21
Medications that Reduce Salivary Flow
22
23
24
Drug/Alcohol Abuse
25
26
27
Clinical Conditions
Rows
Low Risk
Moderate Risk
High Risk
Indicate the conditions that apply.
Cavitated or Non-Cavitated Carious Lesions or Restorations
28
29
30
Teeth Missing Due to Caries in past 36 months
31
32
33
Visible Plaque
34
35
36
Unusual Tooth Morphology that compromises oral hygiene
37
38
39
Interproximal Restorations - 1 or more
40
41
42
Exposed Root Surfaces
43
44
45
Restorations with Overhangs and/or Open Margins; Open Contacts with Food Impaction
46
47
48
Dental/Orthodontic Appliances
49
50
51
Severe Dry Mouth (Xerostomia)
52
53
54
Overall assessment of dental caries at risk:
Low
Moderate
High
Overall Comments
Dentist Name
First Name
Last Name
Dentist Signature
Submit
Should be Empty: