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First, enter your age so we know which questions to ask
How old are you?
 
Tooth health assesment
Questions to help us assess your child's tooth health
Are all of the child's teeth gone?
 
How many teeth has the child had extracted because of decay or abscess?
 
How many fillings and caps has the mother or caregiver had in the last two years?
 
Are Xylitol gum or lozenges used by the mother or caregiver 2-4 times per day?
 
Is the parent eligible for government programs (WIC, Head Start, Medicaid, SCHIP)?
 
 
What is the child's dental care frequency?
 
 
Does the child have any developmental challenges?
 
 
How many fillings has the child had in the last 2 years?
 
 
Does the child have snacks between meals?
 
 
Does the child drink fluoridated water or use fluoride toothpaste or supplements?
 
Does the child sleep with or continually use a bottle that is filled with a fluid other than water?
 
Does the child nurse on demand?
 
Does the child have pain when drinking cold or sweet drinks?
 
Has the child stopped eating foods that require chewing?
 
How many filled teeth does the child have?
 
Does the child complain that his or her mouth is dry?
 
Are all of your adult upper teeth gone?
 
Are all of your adult lower teeth gone?
 
How many false teeth do you have?
 
Do you have missing teeth that you think should be replaced but have not replaced yet?
 
Do your teeth hurt when you drink hot, cold, or sweet beverages?
 
Do your teeth hurt when you chew?
 
How many adult teeth have you had extracted because of decay, looseness, or pain? (not counting wisdom or impacted teeth, or teeth knocked out by an accident or removed for orthodontics)
 
How many adult teeth have you had filled?
 
How many adult teeth have you had capped?
 
How many fillings and caps have you had in the last 2 years?
 
Do you have snacks between meals?
 
Have you had a major health change (like a heart attack, stroke, etc) during the past 12 months?
 
Gum tissue health assessment
Do you ever detect small amounts of blood when you brush your teeth?
 
Have you lost teeth due to an accident?
 
Have you ever been told by a professional that you have bone loss or pockets around one or more teeth?
 
Have you ever had or been advised to have a deep gum cleaning?
 
Have you ever had or been advised to have advanced treatment like gum surgery or laser gum procedure?
Frequency that you use dental floss or other tool to clean between teeth:
The number of gum disease control cleanings called "periodontal maintenance" in the last 24 months:
Do you have a parent or sibling who has or had gum disease?
 
What is your diabetic status?
 
Oral cancer risk assessment
Have you had oral cancer?
 
Do you smoke cigarrettes?
 
Do you use chewing or smokeless tobacco?
 
Do you smoke cigars or pipes?
 
Do you think you may have been infected with HPV (human papilloma virus)?
 
How many alcoholic drinks do you typically have in one week?
 

CONGRATULATIONS! Exam completed.
CONGRATULATIONS! Exam completed.
We do not store any information linking users to results. This test is completely anonymous.