Oral Health Risk Assessment-Check Your Risk!

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* 1. Address

Name *

Address *

City/Town *

State/Province

ZIP/Postal Code *

Email Address

Phone Number

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* 2. Date of Birth

Date / Time

Date

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* 3. Did you enroll through Covered California?

Yes

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* 4. I brush my teeth

After each meal

2 x day

1 x day

Weekly or never

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* 5. I floss my teeth

After each meal

1x day

Weekly

Rarely or never

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* 6. I use a fluoride toothpaste when I brush my teeth

Yes

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* 7. I visit my dentist

Regularly (at least once a year)

Rarely or Never

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* 8. The water I drink is fluoridated.

Yes

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* 9. I eat or drink sugary foods (hard or chewy candy, antacids, breath mints, dried fruit, cakes, caramel, soda, energy drinks, juices, non-dairy creamer, flavored yogurt, etc.) or acidic items (citrus fruits, sports drinks, etc.)

Rarely

a few times a week

frequently and/or often between meals

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* 10. My gums are puffy, sensitive, and bleed when I brush my teeth and/or I think my gums are receding (shrinking).

Yes

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* 11. I have diabetes.

Yes

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* 12. I smoke (cigarettes, a pipe, cigars) or I chew tobacco.

Yes

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* 13. I am pregnant.

Yes

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* 14. I am wearing braces, orthodontic appliances, or partial dentures.

Yes