Gum Disease Risk Assessment Quiz | Gum Disease Fargo, ND | Cornerstone Dental

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(701) 237-3583 3030 49th St S, Fargo, ND 58104

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Name

Email

Phone Number

#1. How Old Are You?

A. 30 years or younger B. 31 to 49 years C. 50+ years

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

A. Yes B. No

#3. Are You Affected by Diabetes?

A. Yes B. No

#4. Is There a History of Diabetes in Your Family?

A. Yes B. No

#5. Have You Been Diagnosed with Heart Disease, High Blood Pressure, or Strokes?

A. Yes B. No

#6. Are You Pregnant?

A. Yes B. No or N/A

#7. Have You Been Diagnosed with Osteoporosis?

A. Yes B. No

#8. Have You Been Told You Have Gum Disease In the Past?

A. Yes B. No

#9. Do Your Gums Bleed When Brushing or Flossing?

A. Yes B. No

#10. Do Your Teeth Appear Longer?

A. Yes B. No

#11. Do You Frequently Have Bad Breath?

A. Yes B. No

#12. How Often Do You Visit Your Dentist?

A. At least twice a year B. Once a year C. Less than once a year

#13. How Often Do You Brush Your Teeth?

A. Twice a day or more B. Once a day C. Less than once a day

#14. How Often Do You Floss?

A. Every day B. 3, maybe 4 times a week C. Less than 3 times per week

#15. How Often Do You Use Mouthwash?

A. 5 to 7 times a week B. Less than 5 times a week

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