Bad Breath, Oral Malodor, Halitosis Questionnaire
1. How long have you been aware of your bad breath?
More Than 3 Years
2. Please rate your breath when it really bothers you.
1 is Barely noticeable, 10 is Induces nausea
3. Has anyone ever told you that you have bad breath?
No. I am the only one who detects it.
Pretty sure they did, based on their reaction.
4. Which health professionals have told you that you have bad breath?
5. Please list all medications, vitamins, herbal and nutritional supplements, pharmaceuticals and minerals that you take each day. Include the daily dosage and any comments.
6. Please list products and remedies that you have tried:
7. Which remedies / products have worked?
8. Is the bad breath:
In the morning
9. Do you believe that bad breath has hampered you in a social or professional situation?
At a social situation
10. I have been examined for bad breath by a:
11. Has there been a recent change in your diet or eating habits?
12. Can you pinpoint where your bad breath is coming from? Please check all that apply.
13. Please provide any additional comments or observations:
Should be Empty: