Oral Ulcer Assessment Survey
Please complete this survey to help us assess and understand your oral ulcer symptoms and their impact.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How many oral ulcers do you currently have?
*
Where are your oral ulcers located?
*
Inner lips
Tongue
Gums
Cheeks (inside)
Palate (roof of mouth)
Other
How long have you had your current ulcer(s)?
*
Please Select
Less than 3 days
3-7 days
1-2 weeks
More than 2 weeks
How would you rate the pain of your oral ulcer(s)?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain possible
10
0 is No pain, 10 is Worst pain possible
Please indicate how much your oral ulcer(s) have affected the following activities in the past week.
*
Rows
Not at all
Mildly
Moderately
Severely
Eating
1
2
3
4
Speaking
5
6
7
8
Swallowing
9
10
11
12
Sleeping
13
14
15
16
Have you experienced any of the following symptoms along with your oral ulcer(s)?
Fever
Swollen lymph nodes
Fatigue
No additional symptoms
Other
Do you know what may have triggered your oral ulcer(s)?
Stress
Injury/trauma (e.g., biting cheek)
Certain foods
No known trigger
Other
Have you used any treatments or remedies for your oral ulcer(s)? If yes, please specify.
Please share any additional comments or details about your experience with oral ulcers.
Submit Assessment
Should be Empty: