Couchman Center for Complete Dentistry
Donald Couchman, DDS
Creating Beautiful Smiles
Call: (719) 593-0263

Healthy Mouth Inventory

Take the Healthy Mouth Test

To receive the best complete dental care in Colorado Springs, please take a few minutes to fill out this brief questionnaire. This will help us and you get a feel for your overall dental health. Please be honest in your responses, as an accurate inventory is one of the best tools we have in helping you meet your goals and expectations.

Is your bite system in harmony?

Is your mouth spreading bacteria through your bloodstream to the rest of your body?

Is your heart being affected by the bacteria from your periodontal disease or tooth decay flowing through your bloodstream?

Is the bacteria in your mouth affecting your pancreas or kidneys?

Is your nutrition affected by what you can eat due to mouth pain or missing teeth?

Is the bacteria in your mouth causing bone loss?

Is the bacteria in your mouth affecting the health of your unborn baby?

Is the bacteria in your mouth telling you about possible HPV being a risk or present?

Is your blood pressure 120/80 or below?

Do you have normal salivary flow (free of dry mouth)?

Are you free from oral cancer after your last oral cancer screening?

Do you have bad breath?

Do you have pain in your mouth or face?

Do you have signs of diabetes?

Do you have signs of heart disease?

Are you free from bleeding when flossing or brushing?

Are your gums swollen?

Do you have inflammation?

Do your gums hurt?

Are you free of plaque?

Are you free from unpleasant taste?

Are you free from loose or moving teeth?

Are you free from gum recession and or tooth abrasion?

Are your gum pocket depths 3mm or less?

Are your teeth aligned and supporting gum tissue health?

Are your teeth free from sensitivity to cold, heat, or pressure?

Are your teeth free from decay, cracked, or broken fillings?

Are your existing fillings or crowns well sealed and free from recurrent decay, cracks, and open margins?

Are your exposed root surfaces free from decay and sensitivity?

Are your teeth free from pain?

Are you free from joint noise, jaw pain, limited opening, and chewing problems?

Are you free from headaches?

Is your jaw tired and aching when you wake up?

Is your jaw tired when you chew gum?

Are you free from abnormal tooth wear or thinning of teeth?

Are you free from teeth that are crooked or rotated that affects function?

Do you smile with confidence?

Are you happy with the overall appearance of your teeth?

Do you like your smile?

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.


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