How often do you brush your teeth?

After each meal
Twice a day
Once a day
Weekly

Do you use fluoridated toothpaste when you brush your teeth?

Yes
No

Do you clean your teeth with dental floss or an interproximal brush?

Yes
No

How often do you floss your teeth?

After each meal
Once a day
Twice a day
Weekly

How often do you visit your dentist?

Regularly
Once a year
Never

Do you have sealants on your teeth?

Yes
No

When was the last time you had your cavity filled?

Within last year
Last 12 to 36 months
Over 5 years ago
As a kid
Never

Do you wear dental braces or partial dentures?

Yes
No

How often do you eat sugary foods? (e.g., hard or chewy candies, dried fruits, flavoured yogurt, cakes, juices, soda, energy drinks, antacids, etc.)

Rarely
Once a day
Often between meals

Do you use products with Xylitol?

Yes
No

Do your gums bleed when flossing or brushing?

Yes
No

Are your gums receding?

Yes
No

Are you pregnant?

Yes
No

Do you have diabetes?

Yes
No

Have you been diagnosed with high blood pressure, heart disease or osteoporosis?

Yes
No

Do you smoke or chew tobacco?

Yes
No

Do you take prescriptions or over-the-counter medications?

Yes
No

Have you lost a tooth because of decay or gum disease?

Yes, within last year
Yes, within 12-36 months
Yes, within 3 years
No

Do any of your teeth feel loose?

Yes
No
Not sure

Have you been diagnosed with or treated for periodontal disease in the past?

Yes
No