What is your email address (the same one you use for logging in)?* This field is required.We'll send you a confirmation once you've completed the survey!

example@example.com

The following questions are related to your oral health and hygiene.

What is your sex?Please provide your biological sex at birth

Male

Female

Prefer not to say or don't identify with the above

How long ago was your last visit to the dentist?

Less than 3 months ago

3 months ago

6-12 months ago

1-2 years ago

Over 2 years ago

I don't remember

Prefer not to say

On average, how many times do you brush your teeth per day?

Prefer not to say

On average, how many times per week do you floss your teeth?

1-3

4-7

More than 8

Prefer not to say

Have you ever experienced any of the following symptoms?Mark all that apply

Persistent bad breath

Tooth pain

Bleeding gums

Loose or lost teeth

Gum discoloration

None of the above

Prefer not to say

Have you ever been diagnosed with gingivitis (gum inflammation)?

YesNo

Were you diagnosed with gingivitis in the last 6 months?

YesNo

Do you currently have any symptoms of gingivitis?Symptoms include: bad breath, gums that are: swollen, dark red, bleeding during brushing/flossing, receding (click here to view more information about the symptoms of gingivitis)

YesNo

Have you ever been diagnosed with periodontitis (gum infection/disease)?

YesNo

Were you diagnosed with periodontitis within the last 6 months?

YesNo

When were you diagnosed?

Do you currently have any symptoms of periodontitis?Symptoms include: bad breath, poor gum health, pus between your teeth and gums, "loose" teeth or space between your gums and teeth, or pain when chewing (click here to view more information about the symptoms of periodontitis)

YesNo

The following questions are related to your general health and wellbeing

What is your impression of your health?

Excellent

Good

Fair

Poor

When did you last have a physical exam?

Less than 6 months ago

Between 6 and 12 months ago

1-2 years ago

Over 2 years ago

Have you ever had any radiation therapy or chemotherapy for a growth, tumor, or other condition?

Yes

Prefer not to say

In the last 2 years, have you ever taken or are now taking steroids (e.g. cortisone)

Yes

Prefer not to say

Do you or have you used any of the following tobacco products?

Smoking (cigarettes, pipe, cigar, etc.)

Snuff

Chew

Bidis

I don't use tobacco products

How many times per week?

For how many years?Use decimals for partial years (i.e. "6 months" would be "0.5")

The following 3 questions only apply to females. Please click "yes" to answer them if you are female, and "no" to skip them if you are male.

Yes

I prefer not to say and skip these questions

Are you pregnant?

Yes

Prefer not to say

Are you taking birth control pills, fertility drugs, or hormonal replacement?

Yes

Prefer not to say

The following questions are related to your medical history. Please respond to the same basic question for all indications:

Do you have, or have you ever had, the following diseases, problems, or symptoms?

If you have experienced a condition but don't want to be specific, please mark "other". If none apply, just click "Next" and proceed to the following question.

Cardiovascular/Heart ProblemsPlease mark the applicable condition(s)

Rheumatic fever/heart disease

Artificial heart valves

Congenital heart defect

Heart murmur

Mitral valve prolapse

Angina (chest pain)

Heart attack

Heart failure

Coronary heart disease

High blood pressure

Low blood pressure

Arteriosclerosis

Palpitations

Arrhythmia

Shortness of breath

Swelling of ankles

Pacemaker

Implantable defibrillator

Respiratory/Lung ProblemsPlease mark the applicable condition(s)

Asthma

Emphysema/COPD

Sarcoidosis

Pneumonia

Sinusitis

Bronchitis

Persistant Cough

Sleep Apnea

Snoring

Diabetes/Endocrine DisordersPlease mark the applicable condition(s)

Diabetes

Thyroid problems

Adrenal gland disorder

Kidney/Urological DisordersPlease mark the applicable condition(s)

Kidney stones

Prostate

Renal failure/insufficiency

Frequent urination

Dialysis

Cancer/TumorsPlease mark the applicable condition(s)

Malignant

Benign

Prefer not to say

Neurologic/Nerve ProblemsPlease mark the applicable condition(s)

Stroke

TIA (transient ischemic attack)

Seizures/epilepsy

Multiple sclerosis

Parkinson's disease

Neuropathies

Dementia/Alzheimer's (memory loss)

Headache

Fainting or dizzy spells

Weakness

Feeling of tingling or numbness

Mental health disorder

Post-traumatic stress disorder

Obsessive/compulsive disorder

ADD/ADHD (attention deficit disorder)

Feelings of anxiety

Feelings of depression

Blood/Hematologic DisordersPlease mark the applicable condition(s)

Anemia

Thalassemia

Sickle cell disease/trait

Deep vain thrombosis

Bruise easily

Leukemia

Lymphoma

Multiple myeloma

Bleeding disorders

Gastrointestinal (GI) disordersPlease mark the applicable condition(s)

Cirrhosis/chronic hepatitis

Jaundice (skin/eyes turn yellow)

Hepatitis

Heart burn

Acid reflux (GERD)

Gall stones

Ulcers

Crohn's disease

Irritable bowel syndrome (IBD/IBS)

Musculoskeletal/Connective Tissue DisordersPlease mark the applicable condition(s)

Arthritis

Osteoporosis

Gout

Temporomandibular joint disorder

Lupus

Sclerodema

Fibromyalgia

Joint replacement

Infectious DiseasePlease mark all applicable condition(s)

HIV

AIDS

Methicillin-resistant Staph aureus (MRSA)

STD (sexually transmitted disease)

Coldsores

Mononucleosis

Head/Eye/Ear/Nose/Throat ProblemsPlease mark all applicable condition(s)

Vision problems

Cataract

Wear contact lenses/glasses

Hearing impairment

Glaucoma

Dermatologic/Skin ProblemsPlease mark all applicable condition(s)

Psoriasis

Are you taking any medication related to immunosuppression?

Yes

Is there anything we missed that you would like to share related to your general or oral health?

Yes

If yes, please describe