Free Caries Risk Assessment Form

Assess dental health effectively with Template.net’s Caries Risk Assessment Form Template. This fully customizable and editable form is designed to help dental professionals evaluate the risk of caries development. Utilize the Ai Editor Tool to easily modify the template to meet specific patient needs, ensuring accurate and personalized risk assessments for optimal dental care.

	Low Risk	High Risk	High Risk	Indicate the conditions that apply
Fluoride Exposure
Sugary Foods or Drinks
Caries Experiences of Mother, Caregiver and other Siblings
Dental Home

	Low Risk	High Risk	High Risk	Indicate the conditions that apply
Chemo/Radiation
Eating Disorders
Medications that Reduce Salivary Flow
Drug/Alcohol Abuse

	Low Risk	High Risk	High Risk	Indicate the conditions that apply
Cavitated or Non-Cavitated Carious Lesions or Restorations
Teeth Missing Due to Caries in past 36 months
Visible Plaque
Drug/Alcohol Abuse
Interproximal Restorations - 1 or more
Exposed Root Surfaces
Restorations with Overhangs and/or Open Margins; Open Contacts with Food Impaction

Free Caries Risk Assessment Form

Patient Name

Dentist Name

Date

Contributing Conditions

General Health Conditions

Clinical Conditions

Overall assessment of dental caries at risk:

Overall Comments

Dentist Signature

Thank you for submission!

You may also like