| Frequency with which it happens: Answer each of the following questions, pointing to the option that corresponds to the 0 = Never 1 = Almost never 2 = Occasionally 3 = Frequently 4 = Very frequently | |||||
|---|---|---|---|---|---|
| Questions | Answers | ||||
| 1. Have you noticed your gums are swollen and do not look good? | 0 | 1 | 2 | 3 | 4 |
| 2. Have you had difficulty chewing because of mobility and change of position of your teeth? | 0 | 1 | 2 | 3 | 4 |
| 3. Have you felt pain in your gums? | 0 | 1 | 2 | 3 | 4 |
| 4. Have you had sensitive teeth when chewing or due to cold, hot, sweet foods or drinks? | 0 | 1 | 2 | 3 | 4 |
| 5. Have you been worried because of bad taste in your mouth? | 0 | 1 | 2 | 3 | 4 |
| 6. Have you felt uncomfortable because of bad mouth odor? | 0 | 1 | 2 | 3 | 4 |
| 7. Has your oral hygiene been inadequate because of gum bleeding when brushing? | 0 | 1 | 2 | 3 | 4 |
| 8. Have you avoided chewing with all your teeth because of any absence of dental pieces or accumulation and/or food residue between the teeth? | 0 | 1 | 2 | 3 | 4 |
| 9. Have you felt sad about the health condition of your teeth and gums? | 0 | 1 | 2 | 3 | 4 |
| 10. Have you felt embarrassed by the appearance of your teeth and gums? | 0 | 1 | 2 | 3 | 4 |
| 11. Have you had difficulty doing any daily activities because of the state of your teeth or your gum disease? | 0 | 1 | 2 | 3 | 4 |
| 12. Have you avoided any contact with other people because of the state of your teeth or your gum disease? | 0 | 1 | 2 | 3 | 4 |
| 13. Has your general health been affected as a result of your oral health? | 0 | 1 | 2 | 3 | 4 |
| 14. Has your financial situation been affected by the state of your oral health? | 0 | 1 | 2 | 3 | 4 |