Online Checkup Form

WELL DONE, YOUR RISK OF DENTAL PROBLEMS SEEMS TO BE LOW Most of the answers you provided sounded great! Your home care, your diet and your lifestyle seem to be favorable for good oral health. Make sure you keep up regular preventative care for perfect health in the future. TIP: Go back through the form and check which questions you answered with options b, c or d. Note them down and show them to your dentist at your next visit. These are the ‘riskier’ habits or conditions, which may alter you risk in the future.

YOU MAY NOT HAVE ANY SERIOUS PROBLEMS, BUT YOU ARE AT RISK Most of the answers you provided put you at a higher risk of developing dental problems. They point to ‘risky’ habits or conditions, which may be slowly undermining your dental health. Even if you’re not currently experiencing any serious problems, please schedule your next preventative care visit. Your health, lifestyle, habits and diet can change dramatically over a short period of time and this can create problems very quickly. On the same token, once you discuss this with your dentist, you can reverse this trend just as quickly! TIP: Go back through the form and check which questions you answered with options b, c or d. Note them down and show them to your dentist at your next visit. These are the ‘riskier’ habits or conditions you need to discuss with your dentist.

YOU SHOULD SEE YOUR DENTIST IMMEDIATELY Most of the answers you provided put you at very high risk of dental problems. They point to ‘risky’ habits or conditions, which may be severely affecting your dental health. You may already be experiencing pain, yet something may be holding you back from seeing the dentist. No matter when you last saw your dentist, it’s important to revisit your risk profile next time you see them. You may wish to schedule your appointment outside the usual intervals. Find out what can be done to lower your risk of dental problems in the future and how to treat your existing problems promptly before they get much worse. TIP: Go back through the form and check which questions you answered with options b, c or d. Note them down and show them to your dentist at your next visit. These are the ‘riskier’ habits or conditions you need to discuss with your dentist.

1.	How long ago did you have an examination and a clean by a dentist (or dentist and hygienist)?*
		a. Less than a year ago b. More than a year ago c. Never
2.	How long ago did you have xray images taken of your teeth?*
		a. Less than a year ago b. More than a year ago c. Never
3.	When was the last time you had any of the following dental treatment: fillings, extractions, root canal treatment or periodontal treatment?*
		a. Never b. More than a year ago c. Less than a year ago
4.	Do you suffer from high blood pressure, diabetes, cardiovascular disease, anxiety or autoimmune diseases?*
		a. No b. Yes
5.	Are you currently on any medication?*
		a. No b. Yes
6.	Do you smoke (social smoking included)?*
		a. No b. Yes
7.	Do you drink alcohol?*
		a. No b. Yes
8.	Do you suffer from sleep disturbances (sleep apnoea, snoring or insomnia)?*
		a. No b. Yes
9.	Do you suffer from chronic back pain, neck pain or headaches?*
		a. No b. Yes
10.	How often do you brush your teeth per day?*
		a. At least twice b. Once c. Some days I don’t brush them at all
11.	How often do you floss your teeth?*
		a. Every day b. 2-3 times per week c. Rarely at all
12.	Do your gums bleed when you brush or floss your teeth?*
		a. Never b. Sometimes c. Always
13.	Do your teeth ever get sensitive to hot and cold?*
		a. Never b. Sometimes c. Always
14.	Do you currently suffer from any of the following: dry mouth, tooth or muscle pain, bad taste or smell in your mouth, loose teeth, broken teeth or missing fillings?*
		a. No b. Yes
15.	How many meals and snacks do you consume per day (on average)?*
		a. 2-3 b. 3-6 c. 6+
16.	How many times per day (on average) do you consume any of the following: fruit juice, soft drinks, electrolyte drinks, ‘smart water’, energy drinks, sparkling mineral water, sweetened coffee or sweetened tea?*
		a. Very rarely b. 1 c. 2+
17.	How many times per day (on average) do you consume fruit, sweets, confectionery, glucose pastes or chewable vitamin C?*
		a. Very rarely b. 1 c. 2+
18.	Do you exercise, play sport or train for sport events regularly?*
		a. Rarely b. Workout at the gym c. Social sport d. Professional sport e. Regular triathlons/ marathons/ cycling events
19.	Do you wear a mouthguard when playing contact sport? (if you don't play contact sport, you can skip this question")
		a. Not applicable/ Always b. Sometimes c. Never

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