45 Rodney Street, Liverpool, Merseyside L1 9EW

 0151 734 2221


Periodontitis risk self assessment form

Please fill-in this form and we will get back to you shortly.

 

Patient Name

Phone Number

Email

1) HOW OLD ARE YOU?

Under 40
Between 40 and 65
Over 65

 

2) ARE YOU MALE OR FEMALE?

Male
Female

 

3) ARE YOU A SMOKER?

Non smoker
Light smoker (<10 cigarettes/day)
Heavy smoker (>10 cigarettes/day)

 

4) DO YOUR GUMS OFTEN BLEED WHEN YOU BRUSH YOUR TEETH?

No
Every now and then
Yes

 

5) HAVE YOU NOTICED THAT YOUR TEETH ARE BECOMING LOOSE?

No
Yes

 

6) HAVE YOU NOTICED THE PRESENCE OF RECEDING GUMS OR DO YOUR TEETH SEEM TO BE "LONGER"?

No
Yes, in a few teeth
Yes, in many teeth

 

7) DO YOU HAVE REGULAR CHECKUPS (AT LEAST ONCE A YEAR) AT YOUR DENTIST'S FOR NORMAL PROFESSIONAL CLEANING OF YOUR TEETH?

Yes
I don't go that often
No

 

8) DO YOU USE DENTAL FLOSS AND/OR INTERDENTAL BRUSHES ON A REGULAR BASIS?

Yes, every day
Once in a while
Hardly ever

 

9) DO YOU SUFFER FROM HEART DISEASE, OSTEOPOROSIS, OR DIABETES?

No
No, but I feel very stressed
Yes

 

10) HAS YOUR DENTIST EVER TOLD YOU THAT YOU SUFFER FROM GINGIVAL PROBLEMS, GUM INFECTIONS, OR INFLAMMATION?

No
Yes, but I am having treatment
Yes, but I am not doing anything about it

 

11) HAVE ANY OF YOUR TEETH EVER BEEN EXTRACTED FOR PERIODONTAL REASONS OR BECAUSE THEY WERE TOO LOOSE?

No
Yes

 

12) DOES ANYONE IN YOUR FAMILY HAVE, OR HAVE THEY HAD, PROBLEMS WITH THEIR GUMS (PYORRHOEA)?

No
I don’t know
Yes

 

13) DO YOU THINK YOU HAVE, OR HAVE YOU BEEN TOLD THAT YOUR BREATH IS NOT PLEASANT?

No
Yes, every now and then
Yes