Dental Caries Risk Assessment Survey
Please complete this survey in order to help us assess your risk for Dental Caries. When you are finished, we will be able to better recommend dental treatment for you.
- 1.
Do you currently or have you ever consumed recreational drugs?
- A.
Yes
- B.
No
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- 2.
Please begin the patient portion of the Dental Risk Assessment Survey.
- 3.
Does the patient have any plaque or calculus buildup?
- A.
Generalized
- B.
Localized
- C.
Minimal
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- 4.
Are there any visible cavitations in the patients teeth?
- A.
Yes
- B.
No
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- 5.
Do you currently have Sjogren's Syndrome?
- A.
Yes
- B.
No
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- 6.
Has the patient had a cavity in the last 3 years?
- A.
Yes
- B.
No
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- 7.
Are you currently taking or have you ever taken Hypo-salivary Medications?
- A.
Yes
- B.
No
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- 8.
Are you currently receiving or have you ever received Radiation Therapy?
- A.
Yes
- B.
No
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- 9.
Does the patient have a dry mouth?
- A.
Yes
- B.
No
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- 10.
Does the patient have any exposed roots on any teeth?
- A.
Yes
- B.
No
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- 11.
Do you currently or have you ever had GERD?
- A.
Yes
- B.
No
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- 12.
Does the patient display any deep pits or fissures?
- A.
Yes
- B.
No
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- 13.
Has the patient displayed any Radiographic Cavities?
- A.
Yes
- B.
No
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- 14.
Are there any White Spot Lesions in the patient's mouth?
- A.
Yes
- B.
No
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- 15.
Are there any appliances present in the patient's mouth?
- A.
Yes
- B.
No
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- 16.
Is the patient currently using Fluoridated Water?
- A.
Yes
- B.
No
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- 17.
Is the patient currently using Fluoridated Toothpaste?
- A.
Yes
- B.
No
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- 18.
Is the patient currently using Fluoridated Mouthwash?
- A.
Yes
- B.
No
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- 19.
Is the patient currently using Xylitol gum/mints?
- A.
Yes
- B.
No
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- 20.
Is the patient currently using any other protective rinses?
- A.
Yes
- B.
No
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- 21.
How often do you snack between meals per day?
- A.
3+ times
- B.
1-3 times
- C.
Rarely
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- 22.
How often do you consume soda or low pH beverages?
- A.
Often
- B.
Rarely
- C.
Never
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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
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Current Version
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Jul 18, 2022Quiz Edited by
ProProfs Editorial Team -
May 13, 2016Quiz Created by
Mcmahonfamilyden
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