Dental Health Assessment Form
Patient Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Date of Dental Visit
-
Month
-
Day
Year
Date
Caries Table
Overall assessment of the dental caries risk
*
Low risk
Medium risk
High risk
General Health Conditions
Rows
Low Risk
Moderate Risk
High Risk
Action needed
Special Health Care Needs
1
2
3
Sugar Consumption
4
5
6
Medications that Reduce Salivary Flow
7
8
9
Smoking/Alcohol
10
11
12
Teeth Grinding
13
14
15
Fluoride Exposure
16
17
18
6 Months Dental Visit
19
20
21
General Health Conditions
Rows
Low Risk
Moderate Risk
High Risk
Very Satisfied
Special Health Care Needs
Sugar Consumption
Medications that Reduce Salivary Flow
Smoking/Alcohol
Teeth Grinding
Fluoride Exposure
6 Months Dental Visit
Clinical Conditions
Rows
Low Risk
Moderate Risk
High Risk
Treatment needed
Tooth Decay or old/bad condition Restorations
22
23
24
Teeth Missing
25
26
27
Visible Plaque
28
29
30
Crowding teeth/spacing compromises oral hygiene
31
32
33
Heavily filled tooth (>50% coverage)
34
35
36
Gum Recession
37
38
39
Dental Implant/Orthodontic Appliances/Crown & Bridges
40
41
42
Severe Dry Mouth (Xerostomia)/Mouth Breather
43
44
45
Food impaction
46
47
48
Biting deterioration due to teeth shifting
49
50
51
Impacted Wisdom Tooth
52
53
54
Sign of Crack tooth
55
56
57
Overall assessment of dental health at risk:
Low
Moderate
High
Overall Action List
Dentist Name
First Name
Last Name
Dentist Signature
Submit
Should be Empty: