File name: Caries Risk Assessment Form Pdf
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Caries Risk Assessment Form Pdf
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Caries Risk Assessment Form Proposed treatment for improved prognosis: 3M ESPE Dental Conway Avenue St. Paul, MN USA 1 This form is adapted from the . approach that includes age of the individual, risk for caries progression, active surveillance, application of preventive measures, potential, for arresting the disease process, and . Universal Caries Risk Assessment Form (ALL AGES) Pa ent’s FirstName: Pa ent’s Last Name: Date of Birth: Provider Name: Date of Assessment: Low Risk (0 Points) Moderate Risk (1 . Caries Risk Assessment Form (Age >6) Patient Name: Birth Date: Date: Age: Initials: Low Risk Moderate Risk High Risk Contributing Conditions Check or Circle the conditions that apply I. Fluoride Exposure (through drinking water, supplements, professional applications, toothpaste) Yes No II. Sugary Foods or Drinks (including juice, carbonated or. 1 This form is adapted from the American Dental Association Publications — Caries Risk Assessment Form (Age > 6) 2 Weyant RJ, Tracy SL, Anselmo T, Beltran-Aguilar ED, et al. Topical Fluoride for Caries Prevention: Executive Summary of the Updated Clinical Recommendations and Supporting Systematic Review. JADA ;(11) Caries Risk Assessment Form — Children Age 6 and Over/Adults Patient Name: Chart #: Date: YES = CIRCLE YES YES YES YES Date: YES = CIRCLE YES = CIRCLE Assessment Date: Is this (please circle) base tine or recall Disease Indicators (Any one YES signifies likely High Risk and to do a bacteria test**).
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