Dental Caries Risk Assessment Survey
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Do you currently or have you ever had GERD?
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Yes
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No
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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.
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- 2.
Do you currently have Sjogren's Syndrome?
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Yes
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No
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- 3.
Are you currently taking or have you ever taken Hypo-salivary Medications?
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Yes
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No
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- 4.
Are you currently receiving or have you ever received Radiation Therapy?
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Yes
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No
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- 5.
How often do you snack between meals per day?
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3+ times
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1-3 times
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Rarely
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- 6.
How often do you consume soda or low pH beverages?
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Often
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Rarely
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Never
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- 7.
Do you currently or have you ever consumed recreational drugs?
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Yes
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No
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- 8.
Does the patient have any plaque or calculus buildup?
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Generalized
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Localized
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Minimal
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- 9.
Are there any visible cavitations in the patients teeth?
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Yes
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No
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- 10.
Has the patient had a cavity in the last 3 years?
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Yes
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No
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- 11.
Does the patient have a dry mouth?
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Yes
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No
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- 12.
Does the patient have any exposed roots on any teeth?
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Yes
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No
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- 13.
Does the patient display any deep pits or fissures?
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Yes
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No
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- 14.
Has the patient displayed any Radiographic Cavities?
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Yes
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No
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- 15.
Are there any White Spot Lesions in the patient's mouth?
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Yes
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No
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- 16.
Are there any appliances present in the patient's mouth?
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Yes
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No
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- 17.
Is the patient currently using Fluoridated Water?
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Yes
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No
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- 18.
Is the patient currently using Fluoridated Toothpaste?
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Yes
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No
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- 19.
Is the patient currently using Fluoridated Mouthwash?
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Yes
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No
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- 20.
Is the patient currently using Xylitol gum/mints?
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Yes
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No
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- 21.
Is the patient currently using any other protective rinses?
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Yes
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No
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- 22.
Please begin the patient portion of the Dental Risk Assessment Survey.
Quiz Review Timeline (Updated): Jul 18, 2022 +
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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