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Colorado Oral Health Risk Screening

Fill out one form for each DentaQuest plan member in your home so we can give you the best care.

Member Information

Your DentaQuest Member ID number is the 9- or 10-digit number on the front of your card
Your dental plan*

New Member Survey

How would you rate your family's overall oral health?*
Do you currently have any tooth pain or other dental problems?*
Have you seen a dental provider in the last 6 months?*
Have you had to go to the Emergency Department for a dental issue in the past year?*
Do you have any chronic medical conditions or chronic pain?*
Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in?*
Within the past 12 months, were you worried that your food would run out before you got money to buy more?
Do you put off or neglect going to the dentist because of distance or transportation issues?*
In the past 12 months has your electric, gas, oil, or water company threatened to shut off services in your home?*
Preventistry Pulse

PREVENTISTRY PULSE

A newsletter with tips and information to improve your oral health.