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Salivary Screening Intake

Find the right test for your health.

Complete this short health questionnaire so Dr. Najafi's team can match you with the most relevant salivary diagnostic screening.

Your Info Fertility Oral Health Systemic Health

Your Information

Basic details so we can get in touch with your results.

Full Name *

Email *

Phone

Date of Birth

Gender

Female

Male

Non-binary / Other

Prefer not to say

How did you hear about us?

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Pregnancy & Fertility

Oral bacteria can impact fertility and pregnancy outcomes. This helps us identify relevant risk factors.

Are you currently pregnant?

Yes

Not applicable

Are you trying to conceive?

Yes

Not applicable

History of pregnancy loss?

Yes

Prefer not to answer

Any fertility treatments?

Oral Health

Understanding your dental history helps us determine which salivary diagnostic test is most relevant.

When was your last dental visit?

Within the last 6 months

6–12 months ago

1–2 years ago

More than 2 years ago

Have you been diagnosed with gum disease?

Yes

Not sure

Do your gums bleed when brushing or flossing?

Never

Sometimes

Often

Almost every time

Have you had a salivary diagnostic test before?

Yes

Systemic Health Concerns

Select any health areas you're concerned about. Oral bacteria are connected to all of these — salivary testing can reveal hidden risk factors.

Select all that apply:

Heart / Cardiovascular

Diabetes / Blood Sugar

Autoimmune Conditions

Brain / Memory

Chronic Inflammation / Joint Pain

Cancer Risk Screening

Other health concerns

Additional notes or questions

Screening Submitted

Thank you for completing your intake form. Dr. Najafi's team will review your responses and reach out with personalized next steps — including which salivary diagnostic test is right for you.

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