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141 North State Road, Briarcliff Manor, NY 10510

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Dr.Sternberg's Oral Hygiene Center

Are You at Risk for Gum Disease?

Thank You

We have received your form submission and appreciate your feedback. If you have any additional questions or comments please feel free to contact us directly.

We hope to see you again soon!

1. Do your gums bleed when you brush? Yes
No
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2. Does food get caught between your teeth? Yes
No
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3. Have your gums been examined recently with a peridontal probe and the pockets measured? Yes
No
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4. Do your teeth feel loose or are they shifting? Yes
No
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5. Have your gums receded and can you see more of the teeth than you remember at earlier times? Yes
No
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6. Does anyone in your family; mother, brothers, sisters, father - have or have been diagnosed with gum disease or have they lost their teeth? Yes
No
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7. Are you a diabetic? Do you smoke? Yes
No
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8. Do you grind your teeth at night and see excessive wear? Yes
No
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9. Have you avoided dental care because of fear? Yes
No
Don't Know

10. Is keeping your teeth and having a healthy mouth important to you? Yes
No
Don't Know

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Last Updated: August 27th, 2024 10:17 AM