Free Oral Health Check-up

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About me
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ORAL HEALTH CHECK-UP

Fill out the following questionnaire to find out in which areas you can improve your lifestyle to boost your oral health.

1. Do you visit the dentist and dental hygienist at least twice a year? *

yes
no

2. How often do you brush your teeth? *

Less than twice a day
2 or more times per day

3. How do you brush your teeth? *

toothbrush
interdental brush, floss
mouthwash

4. Are you undergoing treatment for periodontitis? *

yes
no
in the past

5. How many times a day do you eat? *

3
5
7

6. Do you regularly consume sugar and/or processed foods? *

yes
no

7. What do you usually drink? *

water
coffee/tea with sugar
coffee/tea without sugar
soft drinks
fruit juice
energiedrinks (Red Bull, Monster)
isotonic drink (aquarius, AH)
Beer/wine

8. Have you ever had an eating disorder? *

yes
no

9. Do you have all your teeth and molars? *

Yes, I have never had a tooth or molar extracted.
No, I have had a tooth or molar extracted before.
I only miss my wisdom teeth.
I am missing a few teeth due to orthodontic treatment.

10. Have you ever had braces? *

Yes, and I still wear a fixed retainer and/or night retainer
Yes, but I don't wear a fixed retainer and/or night retainer
No
Yes, I am currently undergoing orthodontic treatment

11. Are you stressed? *

yes
sometimes
no

12. Do you have time in your day for rest/hobbies? *

yes
no
sometimes

13. Are you using antidepressants? *

yes
no
not anymore

14. How often do you exercise per week? *

1 day or less
2 days
3 days or more

15. How is your sleep? *

good
bad

16. Do you snore? *

yes
no
sometimes

17. Do you have sleep apnea? *

yes
no
I don´t know

18. Do you grind or clench your teeth? *

yes
no
sometimes
I don´t know

19. Do you suck your thumb or have you done so beyond the age of 2 years? *

yes
no

20. Have you ever received treatment from a speech therapist? *

yes
no

21. Do you breathe through your nose or through your mouth? *

nose
mouth
both

22. While you are filling out this form: *

your mouth is open
your mouth is closed
your tongue is on the floor of your mouth
The tip of your tongue is in contact with the back of your front teeth.
Your upper and lower teeth are in contact
Your teeth are not in contact with each other.

23. Do you bite your nails? *

yes
no
not anymore, but I´ve done it for years

24. Do you smoke? *

yes
no
not anymore, but I´ve done it for years

25. Are you taking medication? *

yes
no
sometimes

26. Select whether you have one or more of the following conditions *

Diabetes type 1 or 2
High blood pressure
Reuma
Alzheimer
I´ve had a stroke
I´ve had a heart attack
Asthma
ADHD
Epilepsy
Cancer
None

27. Are you pregnant?

yes
no

28. Do you have or are you starting to have symptoms of menopause?

yes
no

Name *

E-mail *