Child - Health Risk Assessment

Your dental health is of the utmost importance. Please complete the below assessment. Based on your responses, we will make recommendations on the urgency of obtaining dental care. In no way does this assessment replace that of a clinical visit to a dentist. We always recommend you see your dentist regularly.

Patient Date of Birth

Are you currently enrolled with LIBERTY through Covered CA?

YesNo

1. Child has a dental home/receives regular dental care?

YesNo

2. Child has teeth brushed daily?

YesNo

3. Do you live in an area with fluoridated drinking water?

YesNo

4. Does child snack between meals?

YesNo

5. Child often drinks soda, juices, or energy drinks?

YesNo

6. Is English your child’s primary language?

YesNo

7. Child has cavities?

YesNo

8. Mother/primary caregiver has active cavities?

YesNo

9. Child has special health care needs?

YesNo

10. Child has plaque on teeth?

YesNo

11. Child is put to bed with a bottle containing natural or added sugar?

YesNo

12. I consent to receiving text messages from LIBERTY Dental Plan to help manage my oral health.

YesNo

Message

Child - Health Risk Assessment