Name

First

Last

Email

Do you have bleeding gums when brushing or flossing?

Have you noticed any gum recession or longer teeth?

Have you experienced loose teeth?

Do you have bad breath that persists even after brushing?

Have you ever been diagnosed with gum disease (gingivitis or periodontitis)?

Have you had deep cleanings (scaling and root planing) or other periodontal treatments?

Do you smoke or use tobacco products?

Do you have any of the following conditions?

Are you currently taking any medications that affect the gums or immune system (e.g., immunosuppressants, bisphosphonates, calcium channel blockers)?

Do you have a dry mouth (xerostomia) or reduced saliva flow?

Is there a family history of gum disease?

Do you have a family history of early tooth loss?

Do you clench or grind your teeth (bruxism)?

early brushing? family

When was your last dental check-up?

Do you currently see a dentist regularly?

Why are you ordering this test?