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