Pre Pregnancy Dental Precautionary needs Assessment Form

Kigo Dental - Self Assessment form for dental Precautionary needs before Planning pregnancy.

The following is a self-assessment to help you assess dental health and determine if you need to seek professional dental advice before planning a pregnancy. The assessment is meant to be informative but does not substitute for a comprehensive dental evaluation by your dentist or orthodontist to determine your actual risk and condition.

Assessment Form

Self-assessment form for dental treatments before pregnancy.

1. Have you had any dental treatments in the past six months?
Yes No

2. Have you been experiencing any dental pain or discomfort recently?
Yes No

3. Have you noticed any changes in your gum health, such as bad breath, bleeding or swelling?
Yes No

4. Do you have any dental restorations, such as fillings or crowns, that may need to be replaced?
Yes No

5. Have you had any previous complications during pregnancy, such as gestational diabetes or high blood pressure?
Yes No / Not Applicable

6. Have you had a dental exam within the past six months?
Yes No

7. Do you have any missing teeth that need to be replaced?
Yes No

8. Have you ever been diagnosed with dental conditions, such as wisdom teeth problems, gum diseases or cavities?
Yes No

9. Do you have any concerns about the appearance of your teeth, such as discolouration or misalignment?
Yes No

10. Have you ever been diagnosed with a temporomandibular joint disorder (TMJ)? Are you experiencing any jaw pain, stiffness,clicking or difficulty opening your mouth?
Yes No

11. Have you ever had orthodontic treatment (braces), dental implants, dentures or dental bone grafts?
Yes No

12. Do you have any other oral diseases you have been treated for or are yet to be treated for (oral cancer, injury, trauma)?
Yes No

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Note: It’s essential to prioritize dental health before pregnancy, as poor oral health can lead to complications such as premature birth, low birth weight, and preeclampsia. Therefore, it is crucial to consult with your dentist and obstetrician to ensure optimal dental and overall health before pregnancy.

Pre Pregnancy Dental Precautionary needs Assessment Form

Kigo Dental - Self Assessment form for dental Precautionary needs before Planning pregnancy.

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