Periodontal Maintenance Education Form
Help us understand your knowledge, habits, and readiness for periodontal maintenance. Please answer the following questions to support your ongoing dental care.
Full Name
*
First Name
Last Name
How would you rate your understanding of periodontal (gum) disease?
*
Excellent
Good
Fair
Poor
Which of the following home care habits do you practice regularly? (Select all that apply)
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Brushing twice daily
Flossing daily
Using interdental brushes
Using mouthwash
None of the above
Other
How confident are you in performing your home care routine correctly?
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Very confident
Somewhat confident
Not very confident
Not at all confident
Which symptoms of gum disease are you aware of? (Select all that apply)
*
Bleeding gums
Swollen or tender gums
Persistent bad breath
Receding gums
Loose teeth
None of the above
Have you experienced any of the following symptoms in the past month? (Select all that apply)
*
Bleeding when brushing or flossing
Gum tenderness or swelling
Bad breath
None of these
How often do you visit your dental professional for periodontal maintenance?
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Every 3 months
Every 6 months
Once a year
Only when I have symptoms
I have never visited for maintenance
Do you feel you have received clear instructions on how to care for your gums at home?
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Yes, very clear
Somewhat clear
Not clear
I have not received instructions
What barriers, if any, make it difficult for you to maintain your periodontal health? (Select all that apply)
Lack of time
Forgetting
Discomfort or pain
Cost of dental products
Lack of motivation
No barriers
Other
Are you willing to continue regular follow-up visits for periodontal maintenance?
*
Yes
No
Unsure
Please share any questions or concerns you have about periodontal maintenance.
Submit
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