Caries Risk Analysis Input
Form - Patient Age 5 - 8
Prepared by
,
Exam Date:
Last Assessment Date:
Prepared for
Name:
Date of Birth:
Internal Patient ID:
Previser Patient ID:
Patient History and Clinical Data
The tooth most recently
exposed to saliva for the last 12 months
Fluoride products
are used (Fluoridated water, supplements, toothpaste, rinses or
gels)
Months Patient
has been Caries free
Times per day
snacks or beverages containing sugar are consumed between
meals
Oral
Hygiene
Identify the tooth most recently exposed to saliva for the
last 12 months. Complete that tooth's corresponding section
below:
Permanent
Second Molars:
A tooth has been
fractured
A tooth that is present has
root canal fillings and is not restored with a crown
Has fixed orthodontic
appliance
Bruxes, grinds, or
clenches. - OR - Symptoms of habits like occlusal or
incisal wear, tooth facets, or cervical wear exist
Has a pierced tongue or
oral habits like eating ice, playing a musical instrument with
a mouthpiece, or opening a bottle that places excessive stress
on the teeth
Permanent First Molars:
Has fixed orthodontic appliance
Primary Molars:
Liquids other than water are given in the crib or
bed