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Caries Risk Assessment Form Template

Effectively Evaluate Dental Health with This Template

Struggling to identify patients at risk for cavities can lead to missed opportunities for proper dental care. This caries risk assessment form template is designed for dental professionals who want to quickly and accurately evaluate a patient's risk for dental caries. By using this template, you can enhance patient consultations, streamline data collection, and implement personalized treatment plans, ensuring better oral health outcomes. Explore this live template to create effective assessments.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Email address
Phone number
Are you currently taking any medications that may reduce saliva (e.g., antihistamines, antidepressants, diuretics)?
Yes
No
Unsure
Do you experience dry mouth?
Never
Rarely
Sometimes
Often
Always
Do you have any of the following conditions?
Diabetes
Gastroesophageal reflux (GERD)
Sjogren's syndrome or autoimmune condition affecting saliva
History of head or neck radiation
Eating disorder
None of the above
Prefer not to say
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Do you use tobacco or vape products?
Yes
No
Former user
Prefer not to say
In the past 3 years, have you had any new cavities or fillings?
Yes
No
Unsure
Which of the following apply to you right now? (select all that apply)
Orthodontic appliances (braces, aligners, fixed retainers)
Exposed root surfaces or gum recession
None of the above
How often do you consume sugary snacks or drinks between meals?
Never
Rarely
Sometimes
Often
Always
Which sugary or acidic drinks do you consume most often? (select all that apply)
Soda
Energy drinks
Sports drinks
Juice
Sweetened coffee or tea
Flavored milk
Alcoholic mixed drinks
None of the above
On a typical day, how many between-meal sugary exposures do you have?
0
1
2-3
4 or more
Not sure
How often do you brush your teeth with fluoride toothpaste?
Less than once daily
Once daily
Twice daily
3 or more times daily
Not sure
Do you brush before bedtime?
Yes
No
Sometimes
How often do you clean between your teeth (floss, picks, or water flosser)?
Never
Rarely
Sometimes
Often
Always
Do you primarily drink fluoridated tap water?
Yes
No
Sometimes
Unsure
In the last 12 months, have you received professional fluoride treatments (e.g., varnish)?
Yes
No
Unsure
Do you use prescription-strength fluoride toothpaste or gel?
Yes
No
Unsure
Visible plaque level observed
Low
Moderate
High
Not assessed
Clinical caries findings (select all that apply)
No lesions observed
White spot lesions
Cavitated lesions
Root caries
Approximal radiographic lesions
Not assessed
Overall caries risk level
Low
Moderate
High
Extremely high
Undetermined
Recommended preventive measures (select all that apply)
Prescription-strength fluoride toothpaste or gel
In-office fluoride varnish
Xylitol gum or mints (3-5 times/day)
Sealants
Diet counseling
Saliva substitute or stimulant
Silver diamine fluoride (SDF)
Reinforce oral hygiene instruction
Other
Please Specify:
Recommended recall interval
3 months
4 months
6 months
12 months
Other
Please Specify:
Signature of patient, parent, or guardian (type your full name)
Date signed
I confirm the information provided is accurate to the best of my knowledge.
Agree
Disagree
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Paper art illustration depicting a caries risk assessment form for dental evaluation and analysis.

When to use this form

Use this risk screening when you onboard new patients, during recall exams, or before starting orthodontic care. It helps general and pediatric dentists, hygienists, school clinics, and community programs spot early disease and habits that drive decay. If a patient reports frequent snacking, dry mouth, or recent fillings, you can flag elevated risk and prioritize prevention. Pair it with a Dental screening form to capture medical and dental history in one visit, then turn the findings into care steps with a Dental treatment plan form. To manage privacy and authorizations, route consents through your Dental HIPAA form.

Must Ask Caries Risk Assessment Questions

  1. Do you have any new cavities, white-spot lesions, or fillings placed for decay in the past 12 months?

    Recent disease is the strongest predictor of future disease, so this pinpoints who needs closer follow-up. It also signals when to shorten recall intervals and apply in-office fluoride.

  2. How often do you drink sugary beverages or snack between meals?

    Frequency of fermentable carbs drives acid attacks and demineralization. Knowing the pattern lets you set diet goals and decide on sealants or fluoride support.

  3. Do you brush twice daily with fluoride toothpaste and floss at least once a day?

    Protective habits offset risk factors and boost remineralization. If habits are weak, you can target coaching and prescribe higher-strength fluoride.

  4. Do you have dry mouth (from medications, radiation, sleep apnea, or Sjogren's)?

    Low saliva reduces buffering and raises decay risk, especially on root surfaces. If you need to justify high-risk care to payers, document details with the Dental narrative submission form.

  5. When was your last dental visit, and were radiographs taken?

    Regular exams and appropriate imaging help find hidden lesions and track changes over time. If overdue, you can prioritize scheduling and early intervention.

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