No Referral Required

April 16, 2024

Name Email Phone Number
1. 

Are you above 40?

2. 

How often you brush your teeth

3. 

How often do you clean between your teeth with a dental floss or interproximal brush?

4. 

Do your gums bleed when you brush or floss your teeth?

5. 

How often do you have your teeth professionally cleaned by a Dentist or dental hygienist?

6. 

Do any of your teeth feel loose?

7. 

Do your gums appear to be receding away from your teeth?

8. 

Has your dentist or dental hygienist ever told you that you have a gum disease?

9. 

In the past were any of your teeth extracted by a dentist after they became loose or "fell out" by themselves after they became loose?

10. 

In last few months have any new gaps appeared between your teeth or the existent gaps increased in dimension?

11. 

Does any of your immediate family have a history of gum disease?

12. 

Do you smoke or use any tobacco product?

13. 

Do you have diabetes?

14. 

Have you been diagnosed with heart disease, stroke, high blood pressure or osteoporosis?