Ethan Janson DDS - Family & Cosmetic Dentistry / Downtown Seattle / w(206)623-0809  fax (206)623-1113

Halitosis (Bad Breath) Survey

Simply print out these pages and bring them to your next appointment.   Thank you



Your age in years?

Your sex?

Do you ever have dry mouth or a metallic, sour taste?

Do you have post nasal drip?

Do you have allergies?

Does your saliva become thick towards the end of the day?

Do you have a job that requires a great deal of talking?

Do you ever notice a white coating on your tongue?

At what time of day is your breath worst (morning, during day, after meals etc)?

Is your breath worse during your menstrual cycle?

List any medicines you are taking?

Have you ever taken antibiotics for more than 3 weeks at a time (eg for acne etc)?

Are you allergic to sulphur drugs (Bactrim, Flagyl etc)?

Do any of your relatives have a breath problem?

Do you snore?

Are you a mouth breather?

Do you ever notice "white" round globs stuck to your tonsils?

What is the texture of your tongue (rough, smooth, pink, white, coated in back)?

Do you drink milk, eat cheese or other dairy foods?

Do you use breath mints?

Are they sugarless?

Do you drink coffee and does it make your problem worse?

Did you ever use BreathAsure or similar products. Did they work?

Which brand of mouthwash do you use?

How many glasses of water do you drink a day?

Do you ever get mouth canker sores?

Do your gums bleed when you clean them?

Do you smoke. How many a day?

How much alcohol and what types do you drink a day?

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