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42Questions
  • 1
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  • 2
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  • 3

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

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  • 4
    Please provide your biological sex at birth
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  • 5
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  • 6
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  • 9
    Mark all that apply
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  • 10
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  • 11
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  • 12
    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)
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  • 13
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    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)
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  • 17

    The following questions are related to your general health and wellbeing

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  • 21
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  • 24
    Use decimals for partial years (i.e. "6 months" would be "0.5")
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  • 27
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  • 28
    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.

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  • 29
    Please mark the applicable condition(s)
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  • 30
    Please mark the applicable condition(s)
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  • 31
    Please mark the applicable condition(s)
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  • 32
    Please mark the applicable condition(s)
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  • 33
    Please mark the applicable condition(s)
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  • 34
    Please mark the applicable condition(s)
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  • 35
    Please mark the applicable condition(s)
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  • 36
    Please mark the applicable condition(s)
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  • 37
    Please mark the applicable condition(s)
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  • 38
    Please mark all applicable condition(s)
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  • 39
    Please mark all applicable condition(s)
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  • 40
    Please mark all applicable condition(s)
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  • 41
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  • 42
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  • 43
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