Oral Health Risk Factors
Yes No
(If No, proceed to question 2)
The amount that you are presently smoking (Check ALL that apply)
None (quit smoking completely)
An occasional cigarette
A few cigarettes per day
Less than 1 pack of cigarettes per day
1-2 Packs of cigarettes per day
2 or more packs of cigarettes per day
An occasional cigar
Cigars on a daily / regular basis
Occasional pipe smoker
A pipe on a daily / regular basis
If you quit smoking, when did you quit?
Less than 6 months ago
6 months to a year ago
1 to 3 years ago
Over 3 years ago
How many years have you or did you smoke?
Less than 2 years
2-5 years
5-10 years
10-20 years
Over 20 years
Yes No
(If No, proceed to question 3)
Are you STILL using smokeless tobacco or snuff?
Yes No
If no, WHEN did you quit?
Less than 6 months ago
6 months to a year ago
1 to 3 years ago
Over 3 years ago
How many years did you use or have you used smokeless tobacco?
Less than 1 year
1-2 years
2-5 years
Over 5 years
None
Less than 1
1-5 drinks
6-11 drinks
11-20 drinks
Over 20 drinks
Yes No
Yes No
Yes No
Yes No
Yes No
CONSENT - To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient's health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice. I understand that there are no guarantees or warranties in health or dental care.