Tooth Decay Evaluation Form
Assess your risk and signs of tooth decay with this straightforward evaluation. Please answer all questions based on your current oral health and habits.
How often do you brush your teeth each day?
*
Twice or more
Once
Less than once
How often do you consume sugary foods or drinks?
*
Rarely
Occasionally (1-2 times/day)
Frequently (3+ times/day)
How would you rate your overall oral hygiene?
*
1
2
3
4
5
Do you experience tooth sensitivity to hot, cold, or sweet foods?
*
Never
Sometimes
Often
How often do you visit a dentist for check-ups?
*
Every 6 months
Once a year
Less than once a year
Have you noticed any visible holes or dark spots on your teeth?
*
No
Yes, one or two
Yes, several
Do you experience pain when chewing or biting?
*
Never
Sometimes
Often
Please indicate any of the following you have experienced in the last month.
*
Toothache
Bad breath
Bleeding gums
None of the above
Tooth Condition Assessment
*
Rows
No Decay
Early Signs
Advanced Decay
Upper Left
1
2
3
Upper Right
4
5
6
Lower Left
7
8
9
Lower Right
10
11
12
Is there anything else you would like to mention about your teeth or oral health?
Submit Evaluation
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