FREE Online Breath Evaluation

A) Personal Information

B) Questions

1. Your Age
   -- select your age -- 1 - 19 years 20 - 29 years 30 - 39 years 40 - 49 years 50 - 59 years 60+ years
2. Your Sex
   Male      Female     
3. Do you have Dry Mouth?
   Yes      No     
4. Do you have Post Nasal Drip?
   Yes      No     
5. Do you have allergies?
   Yes      No     
6. Do you find your saliva becoming thick towards the end of the day?
   Yes      No     
7. Do you find that you need to clear your throat often during the day?
   Yes      No     
8. Do your teeth hurt when you drink hot or cold liquids?
   Yes      No     
9. Are you taking prescription medication?
   Yes      No     
10. Have you ever taken antibiotics for more than 3 weeks at a time?
    Yes      No     
11. Are you allergic to Sulfa drugs (Bactrim, Flagyl)?
    Yes      No     
12. Have you ever been prescribed or given ANY medication by a physician or dentist for bad breath?
    Yes      No     
13. Do you snore?
    Yes      No     
14. Do you tend to breathe through your mouth?
    Yes      No     
15. Do you still have your tonsils?
    Yes      No     
16. Did you ever notice white round globs stuck in them?
    Yes      No     
17. Does your tongue have a white or yellow coating on it?
    Yes      No     
18. Do you drink milk, eat cheese or other dairy foods?
    Yes      No     
19. Do you snack on candy, gum, or mints containing sugar?
    Yes      No     
20. Do you drink coffee?
    Yes      No     
21. Do you smoke or chew tobacco?
    Yes      No     
22. Do you drink more than 4 alcoholic beverages a week?
    Yes      No     
23. Do you brush and floss every morning?
    Yes      No     
24. Do you brush and floss every evening?
    Yes      No     
25. Do you use toothpaste with a commercial detergent like sodium lauryl sulfate?
    Yes      No     
26. Do you use alcohol based mouthwash?
    Yes      No     
27. Do you drink 4 or more glasses of water a day ?
    Yes      No     
28. Do you ever get canker sores in your mouth?
    Yes      No     
29. Do your gums bleed?
    Yes      No