Caries Risk Assessment Form
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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