Caries Risk Assessment Questionnaire printable pdf download

Caries Risk Assessment Questionnaire

Patient Name ____________________________________________________

Today’s Date ____________________________________________________

Caries Risk Assessment

1. Were there any unusual conditions during gestation (while mother pregnant)?

Yes or No.

If yes, please explain ____________________________________________

2. Was the birth full term? Yes or No

If no, please explain, how many weeks? _________________________________

3. Did child come home from hospital with mom? Yes or No

4. Did child take any medications during first year of life?

Yes or No

If yes, please explain ______________________________________________________

5. Has child had any surgeries or hospitalizations?

If yes, please explain ______________________________________________________

6. Has child had any previous cavities or restorations (fillings)? Yes or No

If yes, please explain as much as possible ______________________________________

7. Have any siblings or parents had cavities or restorations (fillings)?

Yes or No

If yes, please explain ______________________________________________________

8. Does your drinking water have fluoride in it? Yes No Don’t Know

9. Does your child allow brushing and/or flossing? Yes or No

10. How would you describe your child’s diet?__________________________________

________________________________________________________________________

11. Do you believe your child is at risk for developing cavities?_____________________

If yes, why ?_____________________________________________________________

12. Does anyone in your family have a history of “soft teeth”?

_______________________________________________________________________

Name of person completing this form_________________________________________

(Print your name)

Signature________________________________________________________________

Caries Risk Assessment Questionnaire