Cra Form (Adults And Children Age 6+)
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CRA FORM
First name: _____________ Last name: ________________ Date: ________
Adults and Children Age 6+
Due to new research on cavities and what causes them, we know everyone is at risk of developing decay at some point during their lifetime.
The goal of this assessment form and the bacterial screening test is to determine your likelihood of experiencing new decay in the next 12
months. Please fill out the Patient Use section of this form to the best of your ability. These items will be discussed with your dental
professional during your appointment today. Questions about this form? See the back for Q&A.
Would you like a free bacterial screening test to help
yes
no
determine your risk for cavities?
(The test is a quick, painless swab of your teeth.)
If diagnosed at risk for cavities today, would you be interested
yes
maybe
no
in discussing treatment options?
yes
maybe
no
If needed, are you willing to modify your dietary habits?
RISK FACTORS
Do you notice plaque build-up on your teeth between
no
yes
brushings?
no
yes
Do you take medications daily? If yes, how many? (#____)
Do you feel like you have a dry mouth at any time of the day
no
yes
or night?
Do you drink liquids other than water more than 2 times daily
no
yes
between meals?
no
yes
Do you snack daily between meals?
no
yes
Do you have oral appliances present?
Do any of these other health concerns apply to you? (check all
that apply)
Frequent tobacco use
Other drug use
no
yes
Acid reflux
Bulimia
Diabetes
Sjogren s Syndrome
Head/neck radiation therapy
DISEASE INDICATORS
no
yes
New/Progressing Visible Cavitations
no
yes
New/Progressing Approximal Radiographic Radiolucencies
no
yes
New/Active White Spot Lesions
no
yes
Decay History is a Concern
BIOFILM CHALLENGE
CariScreen Bacterial Assessment
(0-1500 low, 1501-9999 high)
low
high
PROFESSIONAL ASSESSMENT SUMMARY
no
yes
Risk Factors are a Concern
no
yes
Disease Indicators are a Concern
no
yes
Biofilm Challenge is a Concern
RISK IDENTIFICATION
Transfer information above to boxes below to determine risk.
N Y
N Y
N Y
N Y
N Y
Risk Factors
Risk Factors
Risk Factors
Risk Factors
Risk Factors
Disease Indicators
Disease Indicators
Disease Indicators
Disease Indicators
Disease Indicators
Biofilm Challenge
Biofilm Challenge
Biofilm Challenge
Biofilm Challenge
Biofilm Challenge
LOW RISK
MODERATE RISK
HIGH RISK
HIGH RISK
HIGH/EXTREME RISK
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