Free Caries Risk Assessment Form Template
Caries Risk Assessment Form
Please complete this form to evaluate and identify the risk factors for dental caries.
Patient Name
Dentist Name
Date
Contributing Conditions
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Low Risk |
High Risk |
High Risk |
Indicate the conditions that apply |
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|---|---|---|---|---|
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Fluoride Exposure |
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Sugary Foods or Drinks |
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Caries Experiences of Mother, Caregiver and other Siblings |
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Dental Home |
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General Health Conditions
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Low Risk |
High Risk |
High Risk |
Indicate the conditions that apply |
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|---|---|---|---|---|
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Chemo/Radiation |
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Eating Disorders |
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Medications that Reduce Salivary Flow |
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Drug/Alcohol Abuse |
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Clinical Conditions
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Low Risk |
High Risk |
High Risk |
Indicate the conditions that apply |
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|---|---|---|---|---|
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Cavitated or Non-Cavitated Carious Lesions or Restorations |
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Teeth Missing Due to Caries in past 36 months |
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Visible Plaque |
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Drug/Alcohol Abuse |
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Interproximal Restorations - 1 or more |
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Exposed Root Surfaces |
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Restorations with Overhangs and/or Open Margins; Open Contacts with Food Impaction |
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Overall assessment of dental caries at risk:
Overall Comments
Dentist Signature
Name:
Date:
Assessment Form Template @ Template.net
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