Skip to content
Call Us Today!
(480) 225-0700
|
info@cleankiss.com
My Account
Remember Me
Register
Cart
Search for:
Home
Shop
Resources
News
Blog
Podcasts
Contact
Search for:
Periodontal Risk Assessment
Steve Hilburn
2026-06-26T16:23:04-07:00
Periodontal Risk Assessment
First Name
Last Name
Email
Your Age
Under 35
35–49
50–69
70+
Do you smoke or use any tobacco products?
Yes
No
Have you been diagnosed with, or do you have signs or symptoms of heart disease, high blood pressure, or stroke?
Yes
No
Have you been diagnosed with osteoporosis?
Yes
No
Have you previously been diagnosed with gum disease or periodontal disease?
Yes
No
Have you tested positive for genetic markers related to periodontal disease, such as IL-1?
Yes
No
I Don't Know
Are your gums receding or making the appearance of your teeth longer?
No
Yes
Have you lost any teeth due to gum disease or periodontal disease?
Yes
No
How many times per day do you brush your teeth?
0
1
2
3 or more
Do you have diabetes?
Yes
No
Do you have a family history — parents or siblings — of diabetes?
Yes
No
Are you pregnant?
Yes
Not Applicable
No
Has a dentist or dental professional recommended you return for cleanings every three months?
Yes
No
Do your gums bleed when brushing or flossing?
Yes
No
Have you noticed that your teeth are loose or that your bite has changed?
Yes
No
How many times per year do you visit the dentist or dental hygienist?
0
1
2
3
4 or more
How many times per day do you use an oral rinse?
0
1
2 or more
Do you take anti-inflammatory and bone support supplements?
Yes
No
Your Periodontal Risk Indicator Score
Educational Disclaimer
I understand this assessment is for educational purposes only and is not a diagnosis or a substitute for professional dental or medical advice.
Submit Form
Close product quick view
×
Title
Page load link
Go to Top
