Caries Risk Member Self-Assessment

2. How many times a day do you brush?

Never or rarely

1 time a day

2 or more times a day

3. Have you had cavities filled in the past 2 years?

No

1

More than 1

4. Have you had a tooth pulled in the last 2 years because of a cavity?

Yes

No

5. Do you frequently drink sugary/sweet drinks? (Soda, Ice-T, Lemonade, Fruit Juices, Energy Drinks)

Yes

No

6. Do you snack frequently on sweets? (Cookies, chocolate, candy bars, ice cream, etc)

Yes

No

7. Do your teeth hurt when you eat or drink something cold?

Yes

No

8. Do your gums bleed when you brush?

Yes

No

9. Do you have severe dry mouth?

Yes

No