Bad Breath, Oral Malodor, Halitosis Questionnaire
1. How long have you been aware of your bad breath?
1-30 days
1-6 months
7-12 months
1-3 years
More than 3 years
2. Please rate your breath when it really bothers you.
1
2
3
4
5
6
7
8
9
10
Barely noticeable
Induces nausea
1 is Barely noticeable, 10 is Induces nausea
3. Has anyone ever told you that you have bad breath?
Yes
Maybe
No. I am the one who detects it.
Pretty sure they did based on their reaction.
4. Which health professionals have told you that you have bad breath?
Dentist
Dental Hygienist
Dental Assistant
Internist
Gastroenterologist
None
Not sure
5. Please list all medications, vitamins, herbal and nutritional supplements, pharmaceuticals and minerals that you take each day. Include the daily dosage and any comments.
6. Please list products and remedies that you have tried:
7. Which remedies / products have worked?
8. Is the bad breath:
Constant
Sporadic
In the morning
At night
After meals
Anytime
Not sure
9. Do you believe that bad breath has hampered you in a social or professional situation?
Yes
At school
No
At a social situation
At work
Not sure
10. I have been examined for bad breath by a:
Gastroenterologist (GI)
Otolaryngologist (ENT)
Dentist
Dental Hygienist
No one
Not sure
11. Has there been a recent change in your diet or eating/drinking habits?
Yes
No
Not sure
12. Can you pinpoint where your bad breath is coming from? Please check all that apply.
No
Yes
Tooth
Gums
Throat
Nose
Stomach
Bridge
13. Please provide any additional comments or observations:
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
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