Smile Health Check

Please enter the name of the dental practitioner you've booked with for your virtual dental consultThis information is in the booking confirmation email where you opened this form. Please make sure your spelling is correct. If you haven't made a virtual dental consult booking yet please leave this field blank.

First Name

Last Name

How often do you clean your teeth or denture(s)?Clean with a toothbrush or similar

Two or three times daily

Once daily

Most days a week

Once or twice a week

A few times a month

Less than once a month

Never

How often do you clean between all your teeth?Clean with floss, toothpicks, interdental brushes or similar

Once or more daily

Most days a week

A few times a month

I only clean teeth where I feel food gets stuck

Less than once a month

Never

What kind of toothpaste do you use most frequently?

Regular commercial brand with fluoride

Whitening, smokers or charcoal toothpaste

Sensitive toothpaste

Kids formulation toothpaste

Fluoride free '"natural" toothpaste

I make my own toothpaste

I don't use toothpaste

What kind of toothbrush do you use most often?

Manual toothbrush

Electric toothbrush

Toothbrush alternative eg miswak stick

I don't use a toothbrush

I don't have teeth to clean

How often do you change your toothbrush?

Every two months

When the colour indicator tells me to

When it gets shaggy

When someone buys me a new one

A couple of times a year

Maybe once a year or even less

How often do you use mouthwash?

Daily

When I've eaten garlic or have been sick

A few times a week

A few times a month

When I have a sore throat or mouth ulcers

Never

Do you use any other mouth care products at least once or more per week?If yes, please share what you use, why and how often

How much do your enjoy cleaning your mouth?* This field is required.Choose from "I hate it" on the left through to "I love it" on the right

Here's your score for your mouth care habitsThe lower the better! You can receive an email that explains what the scores mean once you've completed the survey.

How many times do you usually eat per day, including snacks?

Less than three times daily

Three square meals fills me

Five or six including snack breaks

I nibble all day long

It varies - when I'm hungry or remember to eat

What do you drink most often throughout the day?

Tap water

Milk, mylk, juice or smoothies

Soft or sports drinks

Bottled water - still or sparkling

Tea or coffee NO milk or sugar

Tea or coffee WITH milk or sugar

Alcoholic beverage

How often do you eat processed sugars?Including confectionary, chocolate, snack bars, biscuits, cakes, dried fruit products, fast food, or similar

I've always got something handy to nibble on

Once or twice a day

A few times a week

A few times a month

Less than once a month

How often do you eat food made at home from scratch using whole foods?

Every meal

Once a day

Most meals

A few times a week

Less than once a week

Never

Here's your score for your dietary habitsThe lower the better! You can receive an email that explains what the scores mean once you've completed the survey.

Do you smoke or vape?eg tobacco, marijuana, nicotine e-juice or similar

YESNO

How often do you chew sugar-free gum?

After every meal

Daily

When I need fresher breath

Less than once a week

I chew gum with sugar

Less than once a month

When I've got a dry mouth

Do you suck on products containing sugar more than once per week?Such as boiled lollies or lollipops, mints, cough lollies, butterscotch, medications or similar

YESNO

Do you snore?

Yes

When I've drunk alcohol

Occasionally when I get a head cold

Not that I'm aware of

Do you experience reflux or vomiting?

Yes most days

Yes but it's controlled with medication

Sometimes

Not that I'm aware of

Do you wake up during the night?

Yes I've usually got to get up for the toilet

Yes when I've been drinking alcohol

Sometimes if I'm disturbed by a dream

Not usually

Yes I'm responsible for young kids or a person with special needs

Do you wear a mouthguard for contact sports you may play?

I don't play contact sports

I should wear a mouthguard but I don't

I wear a boil-shaped mouthguard purchased from a store

I wear a mouthguard custom made by a dental professional

Here's your score for your lifestyle habitsThe lower the better! You can receive an email that explains what the scores mean once you've completed the survey.

Let's total your smile score:Mouth care + dietary + lifestyle habits

The ViDe Smile Score report provides health information of a general nature only and does not provide formal oral health advice.* This field is required.

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