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? yes no
2. Are your gums red and/or swollen?yes no
3. Have you lost any of your adult teeth?yes no
4. Do you have bad breath or a foul taste in your mouth?yes no
5. Have you noticed pus draining from your gums?yes no
6. Are your teeth loose or are spaces developing between your teeth?yes no
7. Does your bite feel indifferent?yes no
8. If you wear a partial denture (plate) – does it fit properly?yes no
9. Do your teeth appear too long? Too short?yes no
10. Do you smoke cigarettes?yes no
11. Did your parents lose their teeth?yes no
12. Are you diabetic or is there a family history of diabetes?yes no
13. Are you experiencing undue stress?yes no
14. Do you have heart disease?yes no
15. Women – are you pregnant or planning to become pregnant?yes no
16. Do you have a history of respiratory disease?yes no