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Total Health Checklist:Layout 1
9/13/11
10:45 AM
Page 1
Total Health Checklist
This information will assist the dental professionals in assessing both your oral health
and its impact on your overall health. Please answer completely to the best of your knowledge.
Patient Name (Last Name, First Name) _____________________________________________________________________
Height_____________ Weight_____________
How frequently have you been brushing your teeth?_________________________________________________________
SA
How frequently have you been flossing your teeth?__________________________________________________________
Do your gums bleed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Are your gums sore or swollen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Have your gums receded (do teeth look longer)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Are your teeth loose?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you smoke or use tobacco products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you drink excessively? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have a persistent sore throat or ear pain?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
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Do you have unexplained numbness or pain in the face/neck/mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have a sore or lesion on the lips or mouth that has persisted for 2 weeks or more? . . . . . . . . . . . . . . yes______ no______
Do you have chronic hoarseness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have difficulty chewing, swallowing, or moving the jaw or tongue?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
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Do you have a lump or thickening in the cheek?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you snore or have you been told in the past you snore? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you regularly have excessive daytime sleepiness?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Have you been diagnosed with sleep apnea? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have a heart condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Is there a history of heart disease in your immediate family? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have a family history of diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have high cholesterol? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
Do you have any other health conditions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______
FOR OFFICE USE ONLY
Record Blood Pressure ________________________
Item Code (125-0107)
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Ideal Oral Health Care
SA
Daily brushing and flossing will help keep calculus
formation to a minimum, but it won't completely
prevent it. A professional dental cleaning at least twice
a year is necessary to remove calculus from places your
toothbrush and floss may have missed. Studies
demonstrate that including flossing as part of your oral
care routine can actually help
Ask us
reduce the amount of
about a regular
periodontal disease-causing
bacteria found in the mouth, cleaning schedule
designed for
therefore contributing to
your needs.
healthy teeth and gums.
Oral Health Care During Pregnancy
Maintaining good oral health may be the
best way to stay healthy and prevent disease.
Talk to the Dentist today about any
questions or health concerns you may have.
For more information on
Oral Systemic Health, please visit
www.aaosh.org
Your Mouth Is a Window
Into the Health
of the Rest of Your Body
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Pregnant women are at a higher risk of periodontal
disease due to hormone fluctuations. Because
periodontal disease in pregnant women has been
linked to preterm, low birth-weight babies, it is essential
that you maintain optimal
If you are
oral health care during
pregnant or
pregnancy.
considering becoming
pregnant, ask us about
your periodontal
health so you can
ensure a happy,
healthy pregnancy.
Our dental office is dedicated
to your overall health.
To learn more about how Henry Schein
contributes to improving health around the world, visit
www.henryschein.com/hscares
11DF5576
Item Code (125-0108)
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Page 2
Oral Cancer
Heart Disease
Your mouth is a window into the health of the rest of
your body. It can show signs of systemic disease or
infection before they are visible elsewhere. We are
trained to recognize these signs and administer
testing that can identify disease or potential areas of
concern. Regular dental visits will not only help you
maintain healthy teeth and gums, but may help you
prevent serious health conditions and maintain
optimal overall well being.
Thirty-six thousand new cases of oral cancer are diagnosed
each year. Although we perform a
We may use
visual examination for oral cancer,
an oral cancer
occasionally there are lesions in the
screening device to
mouth that are not visible to the
check
for abnormal
eye. Between visits to the dentist,
perform self-checks and immediately tissue or use saliva
testing to
report any sores or lesions that do
determine your oral
not heal within 14 days to your
cancer risk level.
dentist. Early detection of oral
cancer saves lives.
Heart disease is the leading killer of men and women in the
United States. Researchers have found that people with
periodontal disease are almost twice as likely to suffer from
coronary artery disease as those
If you
without periodontal disease. If
smoke,
and are
you have periodontal disease
diagnosed with
combined with other risk factors
periodontal disease,
for heart disease, we may
your risk of
recommend you seek a medical
developing
heart
evaluation. Periodontal disease
disease is greatly
can also aggravate existing heart
increased. Talk to
conditions, so it is essential to
us today about
get prompt treatment for
quitting .
periodontal disease.
SA
Total Health: Beyond the Mouth
Oral Health Affects Total Health
Periodontal Disease
Oral Cancer and HPV
HPV is a common, sexually
transmitted virus that has
infected more than 20 million
people in the United States,
with approximately 6 million
new cases each year. Many do
not realize they are infected,
since HPV often has no signs
or symptoms. At least one
strain of HPV is now linked to the development of
oral cancer.
If you are
sexually active,
we may recommend a
saliva test to check for
HPV. This will help
determine your risk
level for oral cancer.
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If you show
When gums become infected and
signs of periodontal
inflamed from periodontal disease,
disease, we may
bacteria in plaque can spread and
prescribe further
grow below the gum line. The
testing to rule out
bacteria can then enter into the
associated
blood stream and travel to major
conditions.
organs and begin new infections.
Ongoing research suggests that
periodontal disease may be linked to heart disease,
osteoporosis, and diabetes.
Sleep Disorders
From fifty to
seventy million
Americans suffer
from chronic sleep
disorders like
habitual snoring
and sleep apnea.
Although snoring
can be harmless, it can also be a sign of sleep apnea, which
occurs when the tongue falls back into the throat during
sleep and blocks the airway. People suffering from sleep
apnea can stop breathing for 10 to
If you have
30 seconds or longer, hundreds of
signs of a sleep
times a night. Untreated, sleep
disorder, we may
apnea can contribute to excessive
recommend an
daytime sleepiness as well as an
at-home
sleep test.
increased risk for high blood
We can help you
pressure, heart attack, stroke,
improve your quality
diabetes, obesity, and driving
of sleep.
accidents.
Today we know that diabetes and periodontal disease are
closely linked. Treating and managing one can help improve
the condition of the other. Although diabetics have a high
risk of developing periodontal disease, improving the
periodontal condition can
If you have
help improve management
periodontal disease
of the diabetes.
combined with other
risk factors for
diabetes, we may
recommend you seek
a medical evaluation
and receive immediate
periodontal
treatment.
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Seventy-eight percent of the adult population has some form
of periodontal disease. Periodontal disease is a serious
inflammatory condition, caused by a bacterial infection, that
leads to destruction of the
We may
attachment fibers and
recommend saliva supporting bone that
testing to
hold your teeth in your
determine your
mouth. When fibers are
genetic risk and
destroyed, the gums
current level of
separate from the teeth,
periodontal
forming pockets that
disease.
become infected. As the
disease progresses, the
pockets deepen and more gum tissue and
bone are destroyed. When neglected, teeth
can become loose and fall out. Although
good oral care can help prevent
periodontal disease, research shows that
up to 30% of the population may be
genetically susceptible to the disease.
Despite oral care habits, these people
may be six times more likely to develop
periodontal disease.
Diabetes
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Patient Guide
Screening Options
Periodontal disease is a serious inflammatory condition, caused by a bacterial infection. As the disease
progresses, the pockets deepen and more gum tissue and bone are destroyed. Teeth can become loose
and fall out. Although good oral care can help prevent periodontal
disease, research shows that up to 30% of the population may be
genetically susceptible to the disease. Despite oral care habits,
these people may be six times more likely to develop periodontal
disease. We may recommend saliva testing to determine your
genetic risk and current level of periodontal disease.
Periodontal Evaluation
Saliva Testing
SA
Periodontal Disease
Screening Options
Although we perform a visual examination for oral cancer, occasionally
there are lesions in the mouth that are not visible to the eye. We may use
an oral cancer screening device to check for abnormal tissue. At least one
strain of HPV is now linked to the development of oral cancer. HPV is a
common, sexually transmitted virus that has infected more than 20 million
people in the United States. Many do not realize they are infected, since
HPV often has no signs or symptoms. We may recommend a saliva test to
check for HPV and determine your risk level for oral cancer.
Treatment Options
Oral Cancer Screening
Referral to a Physician
Screening Options
Epworth Sleepiness Scale
www.aadsm.org/selftest.aspx
Home Testing or Sleep Clinic
Treatment Options
Referral to a Physician
Oral Appliance
Continuous Positive Airway
Pressure (CPAP) Therapy
Surgery
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Heart Disease
Oral Cancer Screening
Saliva Testing
Biopsy
M
While snoring can be harmless, it can also be a
sign of sleep apnea, which occurs when the
tongue falls back into the throat during sleep,
blocking the airway. Untreated, sleep apnea can
contribute to excessive daytime sleepiness as well
as an increased risk for high blood pressure, heart
attack, stroke, diabetes, obesity, and driving
accidents. If you have signs of a sleep disorder, we
may recommend an at-home sleep test.
Scaling and Root Planing
Periodontal Surgery
Referral to a Periodontist
Periodontal Disease
Normal
Oral Cancer
Sleep Disorders
Treatment Options
Apnea Incident
Normal Breathing
Screening Options
Diabetes
Today, we know that diabetes and periodontal disease are closely linked.
Treating and managing one can help improve the condition of the other.
Although diabetics have a high risk of developing periodontal disease,
improving the periodontal condition can help improve management of
the diabetes. If you have periodontal disease combined with other risk
factors for diabetes, we may recommend you seek a medical evaluation
and receive immediate periodontal treatment.
Periodontal Evaluation
Heart Disease Risk Factors Review
Treatment Options
Normal Blood Flow
Referral to a Physician
Treatment of Periodontal Disease
Smoking Cessation Program
E
Researchers have found that people with periodontal disease are almost twice as
likely to suffer from coronary artery disease as those without periodontal disease.
If you have periodontal disease combined with other risk factors for heart disease,
we may recommend you seek a medical evaluation. Periodontal disease can also
aggravate existing heart conditions, so it is essential to get prompt treatment for
periodontal disease. If you smoke and are diagnosed with periodontal disease, your
risk of developing heart disease is greatly increased – talk to us about quitting today.
Estimated percentage of people aged
20 years or older with diagnosed and
undiagnosed diabetes, by age group,
United States, 2005–2008
Screening Options
Periodontal Evaluation
Diabetes Risk Test
diabetes.org/risktest
Treatment Options
Referral to a Physician
Treatment of Periodontal Disease
For more information on Oral Systemic Health,
please visit www.aaosh.org
Item Code (125-0110)