Dental Caries Risk Assessment

Please correct the errors described below.

Name

Date of Birth

Date of Visit

Cavities are the leading chronic health condition in children. Please answer the following questions to help us determine whether your child is at high risk for dental problems

For Parent or Guardian to complete:

Does your child have a dentist?

Yes No

If yes, the dentist’s name?

Date of child’s last visit

Does your drinking water have fluoride in it?

Yes No Unsure

If no, does your child take fluoride supplements?

Yes No Unsure

Do you clean your child’s teeth with fluoride toothpaste daily?

Yes No

1. Does more than one day ever go by without brushing or wiping your child’s teeth/gums?

Yes No

2. Does your child go to bed with a bottle or at the breast?

Yes No

3. Does your child carry around a bottle or sippy cup with milk/juice or breast feed on-demand during the day?

Yes No

If yes, how many glasses of juice daily?

5. Has your child had cavities or dental problems before?

Yes No

6. Have you, or anyone in your family, had cavities or dental problems this year?

Yes No

7. Have you ever seen white spots or decay on your child’s teeth?

Yes No

“If my child is referred to a dentist for follow up care, I give my permission to share this information with the dentist.”

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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