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Have any siblings or parents had cavities or restorations fillings 8. Does your drinking water have fluoride in it Yes No Don t Know 9. Did child take any medications during first year of life 5. Has child had any surgeries or hospitalizations 7. Patient Name Today s Date Caries Risk Assessment 1. Were there any unusual conditions during gestation while mother pregnant Yes or No. If yes please explain 2. Do you believe your child is at risk for developing cavities If yes why 12. Does anyone...
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