Caries Risk Assessment Form For Children Aged 0 To 5 Years - Carifree

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CARIES RISK ASSESSMENT FORM – CHILDREN AGED 0 TO 5 YEARS
Patient Name: ________________________________________
Age: __________
Instructions: Circle the answers that apply
FACTORS
HIGH
MODERATE
LOW
1. Caries Risk Indicators
Mother/Caregiver active caries
no
yes
Low Socio-economic
yes
no
2. Dental Conditions
Visible cavitations
yes
no
Cavity in last two years
yes
no
Obvious white spot lesions
no
yes
Obvious plaque on teeth
yes
no
Gingiva bleeds easily
yes
no
Inadequate saliva flow
yes
no
Appliances present
yes
no
No dental home/episodic care
yes
no
3. Medical History
Developmental problems
yes
no
Medication for asthma
yes
no
Medication for hyperactivity
yes
no
Cancer treatment
yes
no
4. Dietary Habits
Continuous bottle use not H
O
yes
no
2
Sleeps with bottle
yes
no
Nurses on demand
yes
no
Frequent snack >3 per day
yes
1-3 times
no
5. Protective Factors
Fluoridated water
no
yes
Fluoridated toothpaste
no
yes
Adequate saliva flow
no
yes
Mother/Caregiver no caries
no
yes
Mother/Caregiver uses Xylitol
no
yes
Regular dental care
no
yes
6. Laboratory Tests
CariScreen
recommended
results
CariCult
recommended
results
*If visible cavitation is present CariCult test is recommended
CARIES RISK ASSESSMENT
HIGH
MODERATE
LOW
PROGNOSIS
POOR
MODERATE
GOOD
As the caregiver of the patient above, I have been given the recommendation to have a CARICULT to determine
bacterial counts as a part of the overall caries risk assessment. I understand the risks and benefits of the test and I
decline, releasing my dentist(s) of any liability associated with declining the test.
Release signature_________________________________________
Date_____________________

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