Contact Information
Name Email Phone

How Are Your Teeth Really Doing?

How old are you?
Have you had any new fillings or crowns (caps) in the last two years?
Have you had any bad adult teeth removed because of decay, gum disease, or pain? (don't count wisdom teeth or teeth removed for braces)
Do you have any false teeth?
Do you have missing teeth that you think should be replaced but have not been replaced yet?
Have you had any pain from chewing, aching, or sensitivity to hot or cold in your mouth during the past year?
Do you frequently snack on sugary or starchy snacks or drink sugared beverages between meals?
During the past 12 months, have you had a major health change such as diabetes, a heart attack, stroke, cancer, etc.?
Do you drink fluoridated water, brush your teeth with a fluoride toothpaste, or use a rinse or gel with flouride in it?
Do you have at least one routine dental exam visit per year?
Does your mouth frequently feel dry?
Are any of your teeth filled or crowned (capped)?
Are all of your teeth gone?

How Are Your Gums Really Doing?

Do you ever detect small amounts of blood when brushing your teeth?
Have you been told by a dental professional that you have bone loss around your teeth?
Have any teeth become loose? (NOT due to an accident)
Have you had 7 or more bad adult teeth removed because of decay, looseness, or pain? (not counting wisdom teeth or teeth knocked out by an accident or removed for braces)
Have you had or are you currently scheduled for a deep cleaning in relation to a gum disease treatment?
Have you ever had gum surgery? (Or are you scheduled to have it?)
I use dental floss (or another device to clean between my teeth)
In the last 2 years how many gum disease maintenance cleanings have you had? (exclude regular cleanings)
What is your diabetic status?

About My Risk for Oral Cancer

Have you had oral cancer?
Do you smoke cigarettes?
Do you use chewing or smokeless tobacco?
Do you smoke cigars or pipes?
How many alcoholic drinks do you typically have in one week?
CONGRATULATIONS! Exam completed.
We do not store any information linking users to results. This test is completely anonymous.