9 Sir John Overall Dr, Helensvale, QLD 4212

8.30 AM – 5.00 PM 9.00 AM – 7.00 PM 9.00 AM – 5.00 PM 7.00 AM – 3.00 PM 8.00 AM – 3.00 PMCLOSEDCLOSED

Periodontal Risk Assessment Questionnaire

Periodontal Risk Assessment Questionnaire

At Dental as Anything we strive to provide you with the highest possible care.

To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly. Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation.

  • Tobacco Use

    Do you now or have you ever used the following:
  • Amounts per day:
  • Used for how many years:
  • If you quit, list what year:
  • Diabetes

    If you are a patient who has diabetes:
  • If you are not a patient who has diabetes:
  • Have you had any of these warning signs of diabetes?
  • Heart attack/Stroke

    Do you have any risk factors for heart disease or stroke?
  • Medications

    Are you taking or have you ever taken any of the following medication?
  • Family history/Genetics

    Is there an immediate family member(s) who currently has or had gum problems in the past?
  • Artificial joint prosthesis

  • 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
  • Women

    The following can adversely affect your gums. Please check all that apply:
  • Stress

  • All patients please complete the following

    Have you noticed any of the following signs of periodontal disease?

8.30 AM – 5.00 PM 9.00 AM – 7.00 PM 9.00 AM – 5.00 PM 7.00 AM – 3.00 PM 8.00 AM – 3.00 PM CLOSED CLOSED

Request a Call Back