Periodontal risk assessment questionnaire

Periodontal Risk Assessment Questionnaire
I. Tobacco Use – Tobacco use is the most significant risk factor for gum disease.
Do you now or have you ever used the following: II. Diabetes – Gum Disease is a common complication associated with diabetes. Untreated gum disease
makes it harder for patients with diabetes to control their blood sugar.
How do you monitor your blood sugar?_________________________________________Who is your physician for diabetes?___________________________________________ IF YOU ARE NOT A PATIENT WHO HAS DIABETES:
Do you have a family history of diabetes? Have you had any of the following warning signs of diabetes? III. Heart Attack / Stroke – Untreated gum disease may increase your risk for hear attack or stroke.
Do you have any risk factors for heart disease or stroke? IV. Medications – A side effect of some medications can cause changes in your gums.
Are you taking or have you ever taken any of the following medications: ____Antiseizure medications. (i.e., Dilantin ®, Tegretol ®, Phenobarbital, etc.) If you answered yes, are you still taking the anti-seizure medication? Other medication:__________________________________________________ _____Calcium Channel Blocker blood pressure medications. (i.e., Procardia ®, Cardizem ®, Norvasc ®, Verapamil ®, etc.)Other medication:__________________________________________________ _____Immunosuppressant therapy (i.e., Prednisone, Azathioprine, Cyclosporins, Corticsteroids, (Asthma-Inhalers), etc.)Other medication:__________________________________________________ V. Family History / Genetics – Is there an immediate family member(s) who currently has or had gum
problems in the past? (i.e., your mother, father or siblings): VI. Heart Murmur / Artificial Joints or Prosthesis – If you have even the slightest amount of gum
inflammation, bacteria from the mouth can enter the bloodstream and may cause a serious infection of the heart or joints.
Do you have a heart murmur or artificial joints? If yes, does your physician recommend antibiotics prior to dental visits? Name of physician:_________________________________________________ *If you answered yes, it is especially important to always keep your gums as healthy and inflammation-free as possible to reduce the chance of bacterial infection originating from the mouth. VII. Females – Females can be at increased risk for gum disease at different points in their lives.
The following factors can adversely affect your gums. Please check all that apply: _____Infrequent care during previous pregnancies Women with osteoporosis have a greater risk for periodontal bone loss.
_____Estrogen Replacement Therapy / Hormone Replacement Therapy (i.e., Prempro ®, Premarin ®, Premphase ®, Fosamax ® Actonel ®, Evista ®, Forteo ®, etc.) Other(s):_________________________________________________________ IIX. Stress - High levels of stress can reduce your body’s immune defense.
IX. Nutrition – Your diet has the potential to affect your periodontal health.
Do you find it difficult to maintain a well-balanced diet? Have you noticed any of the following signs of gum disease? _____Gums that have pulled away from the teeth _____Change in the way your teeth fit together Is it important to keep your teeth for as long as possible? If you have missing teeth, why have you not had them replaced? ________________________________________________________________________________________________________________________ Do you like the appearance of your smile? Do your teeth keep you from eating any specific foods? Patient Name:_____________________________________________________ Date: _____/_____/_____



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