DO NOT LEAVE ANY QUESTIONS UNANSWERED
1. Gender:
Male
Female
2. Race/Ethnicity:
White
African-American
Asian or Pacific Islander
American Indian
Multi-Racial
Unknown (Non White)
Hispanic
3. Oral Hygiene:
Satisfactory
Not Satisfactory
4. Treated Decay:
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5. Presence of Dental Sealants:
Sealants
Not Satisfactory
No Sealants
6. History of Rampant Caries?
(Delay on 7 or more teeth)
Yes
No
No
7. White Spot Lesions?
(White spots on primary max. anteriors). Only Complete for children younger than 5 years of age.
Yes
No
Not Applicable
8. Age:
0 to 11 Mo.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
9. Untreated Decay:
None
Primary Only
Primary and Permanent
Permanent Only
10. Treatment Urgency:
No Obvious Problem
Early Dental Care
Urgent Care
11. Early Childhood Caries?
(Caries history on primary max. anteriors). Only complete for children younger than 5 years of age.
Yes
No
Not Applicable