Caries Risk Assessment Form

This form enables dentists to carry out an assessment of the risk their patients getting caries.  It enables them to conduct an accurate analysisof all possible risks each patient faces.  The format is quite simple and easy to use because of the importance of documenting this information.

Name of patient: __________________________________________________________

Patient’s age: ____________________________________________________________

Patient’s number: _________________________________________________________

Address: ________________________________________________________________

Tel: ____________________________________________________________________

Mobile: _________________________________________________________________

Email: __________________________________________________________________

Name of guardian: ________________________________________________________

Guardian’s address: _______________________________________________________

Tel: ____________________________________________________________________

Mobile: _________________________________________________________________

Email: __________________________________________________________________

Dentist’s name: __________________________________________________________

Address: ________________________________________________________________

Tel: ____________________________________________________________________

Mobile: _________________________________________________________________

Email: __________________________________________________________________

Date of assessment: _______________________________________________________

Describe your assessment of the patient: _______________________________________

________________________________________________________________________

________________________________________________________________________

Describe possible risk to the patient: __________________________________________

_________________________________________________________________________

_______________________________________________________________________

Describe your diagnosis if the patient faces risk: ________________________________

________________________________________________________________________________________________________________________________________________

Provide your prescription for the patient: ______________________________________

________________________________________________________________________________________________________________________________________________

Any additional comments you may have: __________________________________________________

________________________________________________________________________________________________________________________________________________

Patient’s signature: __________________________  Date: ___________________

Guardian’s signature: ________________________  Date: ___________________

Dentist’s signature: __________________________ Date: ___________________

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