No. of Cavities
No. of filled teeth
No. of sugary snacks per day
How often do you brush your teeth in a day?
Are you wearing braces or any other appliance?
When was the last time you visited the dentist (months)
Do your siblings or parents have cavities?
Referring doctor:
Ever had a Pit and Fissure Fillings Done?
Do you use a floride mouthwash?
Do you use a Caries Preventive Toothpaste?
Do you use a Fluoride Varnish?
Is the child a special needs child ?
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