Preventive dental treatments Assessment Form

Kigo Dental - Self Assessment form for the need for preventive dental treatments.

The following is a self-assessment to help you identify factors that may put you or your child in need of preventive dental treatments. The assessment is meant to be informative but does not substitute for a comprehensive evaluation by your dentist or orthodontist to determine your actual risk and condition.

Airway problems Assessment

Be sure to answer all the questions honestly to obtain an accurate score. Hereafter "you" can be related to you, your child, or any person in need of taking this test.

1. How often do you brush your teeth?

Twice a day Once a day Occassionally Rarely / Never

2. How often do you floss your teeth?

Once a day Occassionally Rarely / Never

3. Have you experienced any bad mouth smell in the past year? Are you experiencing any bad mouth smell at present?
Yes Never

4. Have you had any gum disease or gingivitis in the past year? Have you got any teeth extracted because they were not saveable?
Yes No

5. Have you experienced any tooth sensitivity in the past year? Are you experiencing any sensitivity at present?

No Occassional Frequent / Constant

6. Have you had any dental work done, such as fillings, crowns, root canal treatment or dental implants?

No Yes, One or Two Yes, Three or more

7. Are you currently experiencing any pain or discomfort in your teeth or gums?

No Occassional Frequent / Constant

8. Do you have any habits that could negatively impact your dental health, such as smoking or consuming alcoholic drinks?

No Occassionally Frequently or daily

9. Do you have any habits that could cause dental problems, such as teeth grinding or nail biting?

No Occassionally Frequently or daily

10. Do you have any medical conditions that could affect your dental health, such as diabetes or autoimmune disorders?

No Yes, but it is well-controlled Yes, and it is not well-controlled

11. Have you ever had braces or other orthodontic treatment?

No Yes, in the past Yes, Currently

12. How often do you wear a mouthguard when playing sports or engaging in high-risk activities?

Always Sometimes Rarely / never Not Applicable

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Please note that taking care of dental health is essential to overall health and well-being. Maintaining good oral hygiene habits and seeking regular preventive dental treatments can help prevent dental problems and keep smile healthy and bright.

Preventive dental treatments Assessment Form

Kigo Dental - Self Assessment form for the need for preventive dental treatments.

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