Gum Disease Risk Assessment Quiz – Torrance, CA

Name

Email

Phone Number

#1 How Old Are You?

#2 Do You Smoke or Use Any Other Tobacco Products?

#3 Have You Been Diagnosed with Diabetes?

#4 Do You Have a Family History of Diabetes?

#5 Have You Ever Experienced a Heart Attack or Stroke, or Do You Have High Blood Pressure?

#6 Are You Pregnant?

#7 Have You Been Diagnosed with Osteopenia or Osteoporosis?

#8 Have You Ever Been Told You Have Gingivitis or Another Form of Gum Disease?

#9 Do Your Gums Bleed When You Brush or Floss?

#10 Do Your Teeth Look Unusually Long?

#11 Do You Struggle with Frequent and Persistent Bad Breath?

#12 How Often Do You Attend Dental Appointments?

#13 How Many Times Each Day Do You Brush Your Teeth?

#14 How Often Do You Floss?

#15 How Often Do You Use a Mouth Rinse?