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For Adults: General Oral Health Risk Assessment

General Information

1. What is your gender?
  Female
  Male
2. How old are you?
  Less than 30 years old
  Between 30-44 years old
  Between 45-59 years old
  Between 60-74 years old
  More than 74 years old
3. Are you currently pregnant?
  Yes
  No
4. How often do you have snacks between meals?
  Never
  Rarely
  Frequently

Your Health

5. Which of the following describes your general health?
  I rarely get sick and miss work or other daily activities.
  My overall health often interferes with my daily activities, which results in missed
work or personal activities.
  My dental health often interferes with my daily activities, which results in missed work or personal activities.
6. Do you have diabetes?
  I have diabetes and it is controlled. Controlled diabetes is defined as having a Hemoglobin A1c (HbA1c) of less than 7.5 or an estimated Average Glucose (eAG) is less than 168.
  I have diabetes and it is poorly controlled. Poorly controlled diabetes is defined as having a Hemoglobin A1c (HbA1c) of greater than 7.5 or an estimated Average Glucose (eAG) is greater than 168.
  I have diabetes, but don't know my blood glucose score.
  I don't have diabetes.
7. Do you have heart disease?
  Yes
  No
8. Are you currently taking medication for depression?
  Yes
  No
9. How often do you smoke cigarettes?
  I have never smoked cigarettes.
  I used to smoke cigarettes.
  I currently smoke less than a pack of cigarettes per day.
  I currently smoke more than a pack of cigarettes per day.
10. How often do you use chewing or smokeless tobacco?
  I have never used chewing or smokeless tobacco.
  I have used chewing or smokeless tobacco in the past.
  I currently use chewing or smokeless tobacco.
11. How often do you smoke cigars or pipes?
  I have never smoked cigars or pipes.
  I have smoked cigars or pipes in the past.
  I currently smoke cigars or pipes.
12. How many alcoholic drinks do you typically drink per week?
  None
  1 to 7
  8 to 14
  15 or more
13. Do any of the following apply to you?
  It is possible that I have been infected with HPV (human papilloma virus).
  I have had a major change in health like a heart attack or stroke during the past 12 months.
  I have had oral cancer.
  None of these apply.

Your Dental Health

14. Which of the following describes your dental health?
  I think my gums are in good health.
  I think my teeth are in good health.
  My gums bleed when I brush my teeth.
  I have or have had teeth become loose not due to an accident.
  I have been told by a dental professional that I have bone loss around my teeth.
  I had or am currently scheduled for a deep cleaning (scaling & root planing).
  I had or am currently scheduled for gum surgery (periodontal surgery).
  I have a parent or sibling who has or had gum disease.
  My teeth hurt when I drink hot, cold, or sweet beverages.
  My teeth hurt when I chew.
15. How often do you use dental floss or another device to clean between your teeth?
  Never
  Occasionally
  Daily
16. How many adult teeth have you had extracted because of decay, looseness, or pain (not counting wisdom teeth, impacted teeth, teeth knocked out in an accident or teeth removed for orthodontics)?
  None
  1-3 teeth
  4-6 teeth
  7 or more teeth
  I don't know
17. How many routine dental check-ups and cleaning appointments have you had in the last 24 months?
  0
  1 to 2
  3 to 4
  5 or more
18. How many adult teeth have you had to have dental fillings placed due to cavities?
  None
  Less than 5
  More than 5
19. How many adult teeth have you had capped?
  None
  Less than 3
  More than 3
20. How many false teeth do you have?
  None
  Less than 5
  More than 5
21. How many fillings and caps have you had in the last 2 years?
  None
  Less than 5 in the last 2 years
  More than 5 in the last 2 years
22. Do any of the following apply to you?
  I have no upper adult teeth remaining.
  I have no lower adult teeth remaining.
  I have missing teeth that I think should be replaced but this has not yet been done.
  None of these apply.
   
 

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