Highest Standards of Dental Treatment

Periodontal Health History Form/Questionnaire (Gum and Bone Health)

The bacteria that cause periodontal disease are not confined to the mouth. They are carried throughout the blood stream and have the potential to cause health problems that appear in other parts of the body. Please feel free to ask us if you have any questions about the potential links between periodontal disease and other systemic diseases.

  1. Do your gums bleed when you brush? 
  2. Are your gums red and/or swollen?
  3. Have you lost any of your adult teeth?
  4. Do you have bad breath or a foul taste in your mouth?
  5. Have you noticed pus draining from your gums?
  6. Are your teeth loose or are spaces developing between your teeth?
  7. Does your bite feel indifferent?
  8. If you wear a partial denture (plate) - does it fit properly?
  9. Do your teeth appear too long? Too short?
  10. Do you smoke cigarettes?
  11. Did your parents lose their teeth?
  12. Are you diabetic or is there a family history of diabetes?
  13. Are you experiencing undue stress?
  14. Do you have heart disease?
  15. Women - are you pregnant or planning to become pregnant?
  16. Do you have a history of respiratory disease?