Date : ……/……/……. Drug history : Name : …………………………………………………………… If yes, specify : ………………………………….. Contact Number : ………………………………………….

Dental History: Race : ⃞ Arab ⃞ Malaysian ⃞ Fillings : ………………… Age : …………… years ⃞ Male ⃞ Female ⃞ outdoor ⃞ Married ⃞ Pregnant ⃞ Urban ⃞ Yes ⃞ indoor ⃞ None Marital Status : If female, ⃞ Single ⃞ Not pregnant ⃞ once ⃞ >Once ⃞ Healthy ⃞ PD ⃞ Others : …………………… ⃞ Yes ⃞ No

Sex :

Dental Condition Tooth Brushing: Frequency / Day

Occupation :

Periodontal health:

Pigmentation
Residency : ⃞ Rural ⃞ No ⃞ Moderate (5-20/day) Characteristic: ⃞ Diffuse ⃞ Unilateral ⃞ Macule Location: Duration: ……………….. ⃞ Gingiva Chronic illness : ⃞ Diabetes ⃞ Parathyroid ⃞ Yes ⃞ Hypertension ⃞ Cardiac ⃞ No ⃞ Thyroid ⃞ Respiratory ⃞ Palate Color: ⃞ Light brown Skin tone: Any allergy : ⃞ Yes ⃞ No ⃞ Fair ⃞ Moderate ⃞ Dark ⃞ Dark Brown ⃞ Black ⃞ Buccal Mucosa ⃞ Other : …………………………………. ⃞ Focal ⃞ Bilateral ⃞ Papule

Smoking :

⃞ Heavy (>20/day) ⃞ Social

⃞ Others : ………………………………………..

If yes, specify : …………………………………..

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