Oral Health Risk Screening

Health First Colorado (Colorado's Medicaid program) Colorado Child Health Plan Plus (CHP+)

Yes No

I have an intellectual and/or physical disability I am nervous or afraid to visit the dentist I use a wheelchair or stretcher Other (please explain)

Yes No

Diabetes Kidney disease Lung disease Cancer Mental illness or mental health problem Drug or alcohol use or abuse Other (please explain)

Yes No

Colorado Oral Health Risk Screening