Name
Date
/
Day
/
Month
Year
Date
Smoking
Please Select
Not applicable
Yes - smoking is a risk factor for periodontal disease and reduces treatment success. It is recommended to cut down or ideally quit.
Medical History/Medications
Please Select
Not applicable
Diabetes - It is recommended to see your GP or specialist to ensure that your blood sugars are well controlled.
Blood pressure medication - calcium channel blocker medications are associated with gum inflammation.
Other
Your Diagnosis
Please Select
Localised mild periodontal disease
Localised moderate periodontal disease
Localised severe periodontal disease
Generalised mild periodontal disease
Generalised moderate periodontal disease
Generalised severe periodontal disease
Your Risk Level
Please Select
Low
Medium
High
Brushing
Please Select
Continue using your electric toothbrush, focus on brushing the gum line
Change to using an electric toothbrush (Oral B) and focus on brushing the gum line
Continue using manual toothbrush, focus on brushing the gum line
Cleaning between teeth
Please Select
Daily use of interdental brushes
Daily use of interdental brushes and floss
Other
1.
2.
3.
4.
5.
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