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Caries Risk Assessment Form (Age 0-6)

ADA Caries Risk Assessment

Patient Data

Name
Name
First Name
Last Name
Year(s)

Contributing Conditions:

Fluoride Exposure:
(through drinking water, supplements, professional applications, toothpaste)
Sugary Foods or Drinks:
(including juice, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)
Eligible for Government Programs
(WIC, Head Start, Medicaid or SCHIP)
Caries Experience of Mother, Caregiver and/or other Siblings
Dental Home: established patient of record in a dental office
(through drinking water, supplements, professional applications, toothpaste)

General Health Conditions

Special Health Care Needs (developmental, physical, medical or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers)

Clinical Conditions

Visual or Radiographically Evident Restorations/ Cavitated Carious Lesions
Non-cavitated (incipient) Carious Lesions
Teeth Missing Due to Caries
Visible Plaque
Dental/Orthodontic Appliances Present
(fixed or removable)
Salivary Flow
(fixed or removable)

Overall assessment of dental caries risk:

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