Oral Health Assessment

Can we contact you using the email and phone number listed above? Yes No

Has it been more than 12 months since your last dental visit? Yes No

Do you have pain when eating cold, hot, or sugary foods? Yes No

Do you have a broken tooth or teeth? Yes No

Is your mouth dry? Yes No

Do your gums bleed when you brush or floss? Yes No

Have you had any gum (periodontal) treatments? Yes No

Do you wear dentures or partials? Yes No

Are you currently receiving radiation or chemotherapy? Yes No

Do you have a special need that makes it hard for you to see the dentist? Yes No

If yes, which one? (Select all that apply) I have an intellectual and/or physical disability I am nervous or afraid to visit the dentist I use a wheelchair or stretcher Other (please explain)

Are you pregnant? Yes No

Do you have a chronic health problem or illness that makes it hard for you to see the dentist? Yes No

If yes, which one? (Select all that apply) Diabetes Kidney Disease Heart Disease Lung Disease Cancer Mental Illness or Mental Health Problem Drug or Alcohol use or abuse Other (please explain)

Do you have any other type of problem that makes it hard for you to see the dentist? (For example, "I don't have a way to get to the dentist.") Yes No