Gum Disease Self-Check Sheet

Appearance

Chapped lipsLips not touchingOpen-mouth at restCrookedor crowded teeth

Appearance Total Point

Overall health & Risk Factors

Overall health & Risk Factors Total Point

Sleep

Sleep Total Point

Dental Health

Dental Health Total Point

Total

What’s your score :

If you score 15% or more in any of the sections, we invite you for a complementary assessment & treatment plan.

Please mark all that apply