RATE YOUR PERIODONTAL CONDITION

Name:    
Phone:   
Email:     

1. Do your gums bleed when brushing?
   Yes
   No
   
2. Do you have bad breath?
   Yes
   No
   
3. Do your gums bleed when eating?
   Yes
   No
   
4. Are your gums red or pink?
   Pink
   Red
   
5. Are your gums tender when you brush?
   Yes
   No
   
6. Has any dentist/hygenist told you that you have a gum problem?
   Yes
   No
   
7. Has any dentist/hygenist told you that you have a more advanced gum or periodontal condition?
   Yes
   No
   
8. Were you ever treated for periodontal disease?
   Yes
   No
   
9. Do you have allergies ?
   Yes
   No