Questionnaire

Q1

Age

< 35 years old

35 - 44 years old

45 - 64 years old

> 64 years old

Q2

Smoking

No

< 10 cigarettes per day

10 - 15 cigarettes per day

> 15 cigarettes per day

Q3

Diabetes

No

Well controlled (HbA1c < 7%)

Poorly controlled / uncontrolled (≥7%)

Q4

Tooth loss due to periodontal diseases

No tooth loss

Tooth loss due to periodontitis

Q5

Heavy plaque depositis covering

< 10% of tooth sites

10% - 50% of tooth sites

> 50% of tooth sites

Q6

Bleeding on probing

< 10% of tooth sites

10% - 50% of tooth sites

> 50% of tooth sites

Q7

Probing depth

< 4 mm

-- 25

> 4 - 5 mm

-- 26

Localized tooth sites > 5 mm

-- 27

Generalized tooth sites > 5 mm

-- 28