<p>The purpose of this study is to design and evaluate the accuracy and validity of a self-reported questionnaire for the detection of peri-implant disease among implant patients in a graduate periodontics dental clinic. The questionnaire was adapted from previously validated self-reported questionnaires designed to screen for periodontitis. Items were created by identifying established and suspected risk factors for peri-implant disease. Implant patients attending a graduate periodontics clinic were recruited for a self-report survey. A standard implant recall examination was then conducted. Patients’ peri-implant health status was compared to questionnaire answers using Chi squared and Fisher’s exact tests. The predictive value of the survey was measured using the area under the Receiver Operator Curve (AUC). A total of 26 patients with 52 implants were included. One participant (3.8%) was diagnosed with peri-implantitis, and 6 participants (23.1%) were diagnosed with peri-implant mucositis of one or more implants. Peri-implant food impaction was significantly correlated with the presence of peri-implant mucositis (Fisher’s <i>p</i> = 0.009). The calculated AUC for the entire questionnaire was 0.571. The AUC values for individual questions reveal that ‘food impaction’ (AUC = 0.812), ‘last dental cleaning’ (AUC = 0.650) and ‘frequency of toothbrushing’ (AUC = 0.643) were the strongest predictors of peri-implant disease. Within the limitations of this study, it may be concluded that questionnaire items focusing on peri-implant food impaction, oral hygiene habits, and periodontal maintenance frequency, have the potential to screen for peri-implant disease.</p>