Patient Information Form

PERIODONTAL (GUM) DISEASE RISK ASSESSMENT:
Did you know that:

Gum inflammation is a prime risk factor for heart disease, heart attack, hypertension and stroke

Dangerous oral bacteria can migrate through the bloodstream to infect your heart and other vital organs

Gum inflammation is also linked to Alzheimer's Disease, Diabetes, Kidney Disease, Colon Cancer and Osteosporosis

Gum inflammation puts pregnat women at risk of preterm, low-birth weight babies and other fetal complications
Do you have Periodontal Disease? Yes=2 points, Occasionally=1 point, No=0 points
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
1. Do your gums bleed when you brush or floss?
2. Do your gums appear red (Do they match your lips rather than your skin)?
3. Do you suffer from bad breath?
4. Do you have any loose teeth or teeth that have shifted?
5. Do you smoke?
6. Are there areas on your gums that ever get swollen or sore?
7. Do you get food wedged between your teeth?
8. Do you see exposed roots at the gum line?
9. Are your teeth sensitive to cold temperatures?
10. Have you ever been told you have " Gingivitis," "Bone Loss," or "Gum Disease?"
11. Has it been more than a year since your last professional dental cleaning?
12. Have your parents or siblings lost teeth due to periodontal disease?
Score total points:

0-3 Unlikely host of periodontal disease: learn more about prevention

4-6 low suspicion of localized periodontal disease/inflammation: seek consultation

7-10 moderate suspsicion of generalized disease: seek consultation

11+ high suspicion of generalized disease: get immediate attention
Should be Empty:

PERIODONTAL (GUM) DISEASE RISK ASSESSMENT:

Did you know that: