"*" indicates required fields

Do you have any persistent ulcers (lasting more than 3 weeks for one specific ulcer) or white patches?*
Do you smoke over 5 cigarettes per day and/or chew tobacco?*
Are your gums red, swollen, or bleeding on flossing and brushing?*
Did your parents lose their teeth before the age of 60?*
Do you drink juices or soda daily?*
Do you suck sweets, mints, or jellies more than once per day?*
Do you take sugar in tea or coffee?*
Do you have any overt holes in your teeth?*
Have you had a seemingly healthy tooth break in the past without warning?*
Are your teeth more crowded than before when you were younger?*
Are your lower front teeth short and flat on the tip?*
Do you get headaches or earaches more than once per week?*
Do you have difficulty holding your mouth open?*
This field is for validation purposes and should be left unchanged.