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ONLINE CHECK UP FORM

1. How long ago did you have an examination and a clean by a dentist (or dentist and hygienist)?*
a. Less than a year ago
b. More than a year ago
c. Never
2. How long ago did you have xray images taken of your teeth?*
a. Less than a year ago
b. More than a year ago
c. Never
3. When was the last time you had any of the following dental treatment: fillings, extractions, root canal treatment or periodontal treatment?*
a. Never
b. More than a year ago
c. Less than a year ago
4. Do you suffer from high blood pressure, diabetes, cardiovascular disease, anxiety or autoimmune diseases?*
a. No
b. Yes
5. Are you currently on any medication?*
a. No
b. Yes
6. Do you smoke (social smoking included)?*
a. No
b. Yes
7. Do you drink alcohol?*
a. No
b. Yes
8. Do you suffer from sleep disturbances (sleep apnoea, snoring or insomnia)?*
a. No
b. Yes
9. Do you suffer from chronic back pain, neck pain or headaches?*
a. No
b. Yes
10. How often do you brush your teeth per day?*
a. At least twice
b. Once
c. Some days I don’t brush them at all
11. How often do you floss your teeth?*
a. Every day
b. 2-3 times per week
c. Rarely at all
12. Do your gums bleed when you brush or floss your teeth?*
a. Never
b. Sometimes
c. Always
13. Do your teeth ever get sensitive to hot and cold?*
a. Never
b. Sometimes
c. Always
14. Do you currently suffer from any of the following: dry mouth, tooth or muscle pain, bad taste or smell in your mouth, loose teeth, broken teeth or missing fillings?*
a. No
b. Yes
15. How many meals and snacks do you consume per day (on average)?*
a. 2-3
b. 3-6
 c. 6+
16. How many times per day (on average) do you consume any of the following: fruit juice, soft drinks, electrolyte drinks, ‘smart water’, energy drinks, sparkling mineral water, sweetened coffee or sweetened tea?*
a. Very rarely
b. 1
c. 2+
17. How many times per day (on average) do you consume fruit, sweets, confectionery, glucose pastes or chewable vitamin C?*
a. Very rarely
b. 1
c. 2+
18. Do you exercise, play sport or train for sport events regularly?*
a. Rarely
b. Workout at the gym
c. Social sport
d. Professional sport
e. Regular triathlons/ marathons/ cycling events
19. Do you wear a mouthguard when playing contact sport? (if you don't play contact sport, you can skip this question")
a. Not applicable/ Always
b. Sometimes
c. Never

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Dr Catherine-Anne Walsh
We are here to educate, motivate and inspire you to gain and retain control over your dental health.
Dr Catherine Anne Walsh