Pregnant | Yes â–¡ | No â–¡ | Â | Â |
Smoker | Yes â–¡ | No â–¡ | If yes, number per day | Â |
Dentures | Yes â–¡ | No â–¡ | Full â–¡ exclude | Partial: number of dentures 1 â–¡ 2 â–¡ |
Total number of teeth | Â | Â | ||
Number of restorations and crowns | None â–¡ | Â | ||
 |  |  | 1 - 9 □ |  |
 |  |  | 10 + □ |  |