Bad Breath, Oral Malodor, Halitosis Questionnaire
1. How long have you been aware of your bad breath?
1-30 Days
1-6 Months
7-12 Months
1-3 Years
More Than 3 Years
Other
2. Please rate your breath when it really bothers you.
Barely noticeable
1
2
3
4
5
6
7
8
9
Induces nausea
10
1 is Barely noticeable, 10 is Induces nausea
3. Has anyone ever told you that you have bad breath?
Yes
No. I am the only one who detects it.
Maybe
Pretty sure they did, based on their reaction.
Other
4. Which health professionals have told you that you have bad breath?
Dentist
Dental hygienist
Dental assistant
Internist
Gastroenterologist
None
Not sure
Other
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:
Constant
Sporadic
In the morning
At night
After meals
Anytime
Not sure
Other
9. Do you believe that bad breath has hampered you in a social or professional situation?
Yes
At school
At a social situation
No
Not sure
At work
Other
10. I have been examined for bad breath by a:
Gastroenterologist (GI)
Otolaryngologist (ENT)
Dentist
Dental hygienist
No one
Not sure
Other
11. Has there been a recent change in your diet or eating habits?
No
Yes
Not sure
12. Can you pinpoint where your bad breath is coming from? Please check all that apply.
No
Yes
Tooth
Gums
Throat
Nose
Stomach
Bridge
Other
13. Please provide any additional comments or observations:
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Submit
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