Information
Please enter your Name and Email address
Name
*
First Name
Last Name
Email
*
example@example.com
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General Questions
Please answer the following questions:
Are you at least 13 years old?
*
Yes
No
Have you had a dental examination in the past 2 years?
*
Yes
No
Are you happy with the color of your teeth?
*
Yes
No
Submit
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Cavity Risk Factors
Please answer the following questions:
Do you snack more than 3 times a day between meals?
*
Yes
No
Do you often drink sweet beverages (soda, juice, sports drinks, energy drinks, sweetened coffee, smoothies, sweet tea, etc.)?
*
Yes
No
Do you experience cold or sweet-sensitive teeth, bad breath or sticky dental plaque?
*
Yes
No
Do you have recreational drug usage?
*
Yes
No
Do you wear any of the following: braces, retainer, partial denture, bite guard, or oral snore guard?
*
Yes
No
Do any of the following apply to you? Take one or more prescription medications, often take over-the-counter medications, use drugs recreationally, have received head and neck radiation treatments, or been diagnosed with Sjogren’s syndrome.
*
Yes
No
Do you experience dry mouth, either daytime or at night?
*
Yes
No
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Brushing Habits
Please answer the following questions:
How often do you brush with a fluoride toothpaste?
Not every day
At least once a day
At least twice a day
I don’t use fluoride toothpaste
Do you use an electric toothbrush?
Yes
No
Do you floss your teeth?
Once a Day
Twice a Day
Not Every Day
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Protective Factors
Please answer the following questions:
Do you use a fluoride mouth rinse daily? Note: Not all mouth rinses contain fluoride.
Yes
No
Have you received a fluoride varnish treatment by a dental professional in the past 6 months?
Yes
No
Do you use xylitol gum or mints daily?
Yes
No
Do you live, work, or attend school in a community with fluoridated drinking water AND drink tap water?
Yes
No
Not Sure
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Gum Health
Please answer the following questions:
Do you floss at least once a day?
Yes
No
Do your gums bleed easily when flossing or brushing?
Yes
No
Do you have puffy and swollen gums, or gums that are sensitive to pain?
Yes
No
Do you have recession around your gum line?
Yes
No
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Teeth Whitening
Please answer the following questions:
If you are not satisfied, what is the color of your teeth?
Light Grey/ LightYellow
Yellow
Brown
N/A
Do you have previous trauma to affected teeth?
Yes
No
Does your family have a history of tetracycline usage?
Yes
No
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Traditional Medicine
Please answer the following questions:
Are you interested in using traditional medicine?
Yes
No
Are you looking to avoid fluoride products?
Yes
No
Do you get sores inside your mouth including your lips, cheeks, gums, tongue, and floor and roof of your mouth
Yes
No
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Traditional Medicine (Mouth Ulcers)
Please choose the best description of your ulcers:
Visible mouth sores ranging from three to five, burning pain, surface yellowish white secretions, red and swollen around, upset insomnia, thirst bad breath, dry stool, short yellow urine, red tongue yellow, slippery pulse.
The sore is swollen or blisters. Often accompanied by fever, headache, sore throat, cough, thirst, constipation, urine yellow, red tongue yellow, pulse number.
Visible repeated episodes of mouth sores, burning pain, sore redness, dry mouth, dry throat, dizziness, tinnitus, insomnia and more dreams, palpitations, forgetfulness, weak waist, hands and feet, hot red tongue, less moss, pulse breakdown.
Visible mouth sores are not red, large and deep, the surface is gray, long-term unhealed, taking cold medicine is aggravated, abdominal distension is less, loose stools, dizziness, fatigue, or waist and knees, cold face, cold mouth, tasteless , pale tongue, white fur, weak pulse or large force
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