GINGIVITIS
Gingivitis is often painful inflammation of the gums. It typically occurs due to plague buildup
on the teeth and often treatable with oral hygiene improvements.
INSTRUCTION:Please complete the following questionnaire with specific regard to above enquiry by placing a
tick on appropriate option.
Do you now, or have you in the past, suffered from any of the following conditions ?
Allergies Yes No Anemia Yes No Asthma Yes No
Diabetes Yes No Gum Disease Yes No Stroke Yes No
High blood
pressure Yes No Osteoporosis Yes No Pregnancy Yes No
Are your gums receding or making Yes No Uncertain
the appearance of your teeth longer?
How often do you floss between your Daily 3- Less than
teeth ? 4times 3 times a
a week week
How often do you visit a dentist ? Monthly 6 Yearly
months
ARE YOU CURRENTLY UNDER A PHYSICIAN’S CARE FOR ANY
YES NO
CHRONIC CINDITION OR ILLNESS?
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS? YES NO
DO YOUR GUMS BLEED? YES NO
HAVE YOU NOTICED THAT YOUR TEETH ARE LOOSE OR THAT YOUR
YES NO
BITE HAS CHANGED?
HAVE YOU HAD A TOOTH OR TEETH ( OTHER THAN YOUR WISDOM
YES NO
TEETH ) REMOVED DUE TO GUM DISEASE?
DO YOU FREQUENTLY HAVE BAD BREATH?
YES NO
HAS A DENTIST OR DENTAL PROFESSIONAL EVER TOLD YOU THAT
YOU HAVE A GUM DISEASE OR HAVE BEEN TREATED FOR GUM YES NO
DISEASE?
