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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

Do you have tooth pain or a dental problem right now?*
Have you been to the Emergency Room for a dental problem in the past 12 months?*
Was your last visit to the dentist more than 12 months ago?*
Do you brush your teeth less than twice a day?*
Do you smoke or use tobacco/vaping products?*
If yes, would you like assistance to stop using tobacco/vaping products?
Do you have a special need that makes it hard to see the dentist?*
If yes, which one? (Select all that apply)
Are you pregnant?*
Do you have a health problem or illness that makes it hard for you to see the dentist?*
If yes, which one? (Select all that apply)
Do you have any other type of problem that makes it hard for you to see the dentist? (For example, "I don't have a way to get to the dentist.")*
Preventistry Pulse

PREVENTISTRY PULSE

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