| 1. Do our gums bleed when you brush your teeth? | Yes | No |
| 2. Are your gums red, swollen or tender? | Yes | No |
| 3. Have your gums pulled away (receded) from your teeth? | Yes | No |
| 4. Is there pus between your teeth and gums when gums are pressed? | Yes | No |
| 5. Are your permanent teeth loose or separating? | Yes | No |
| 6. Is there a change in the way your teeth fit when biting? | Yes | No |
| 7. Is there a change in the way your partial dentures fit? | Yes | No |
| 8. Do you have persistent bad breath? | Yes | No |
