MutualOmaha Dental

1.

Do you smoke cigarettes or use other tobacco products?

Yes

No

3.

Do you have difficulty in swallowing as a result of feeling something caught in your throat?

Yes

No

5.

Do you have red or white patches in the mouth or on the tongue that do not heal?

Yes

No

6.

Do you have unexplained bleeding in the mouth?

Yes

No

8.

Do you have any numbness or a tingling sensation in the mouth or on the face or neck?

Yes

No

9.

Do you have a lump or swelling in the neck or jaw?

Yes

No


1.	Do you smoke cigarettes or use other tobacco products?	Yes	No
2.	Do you drink more than two alcoholic drinks per day?	Yes	No
3.	Do you have difficulty in swallowing as a result of feeling something caught in your throat?	Yes	No
4.	Do you have a chronic sore throat or hoarseness of the voice?	Yes	No
5.	Do you have red or white patches in the mouth or on the tongue that do not heal?	Yes	No
6.	Do you have unexplained bleeding in the mouth?	Yes	No
7.	Do you have a lump or a tissue growth anywhere in your mouth?	Yes	No
8.	Do you have any numbness or a tingling sensation in the mouth or on the face or neck?	Yes	No
9.	Do you have a lump or swelling in the neck or jaw?	Yes	No

Assess Your Risk for Oral Cancer