Chart #	Date:	Date:	Date:	Date:	Date:	Date:
	Answer	Answer	Answer	Answer	Answer	Answer
Risk Factors
1. Visible heavy plaque on teeth	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
Protective factors
2. Drinks fluorinated water from municipal supply	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
3. Fluoride toothpaste at least once a day	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
4. Fluoride toothpaste at least 2xday	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
5. Fluoride mouth rinse (0.05%NaF) daily	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
6.5000 ppm F fluoride toothpaste daily	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
7. Chlorhexidine prescribed/used one week each of last 6 months	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
8. Xylitol gum/lozenges 4x daily last 6 months	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
9.MI paste during last 6 months	Y/N	Y/N	Y/N	Y/N	Y/N	Y/N
Summary
# of YES Risk Factors
# of YES Protective Factors