2018 SHD Form 2

DENTAL FINDINGS
Medical History Guide Questions
Yes No Remarks Do you have a toothbrush? Y__

Allergy How many times do you brush yo

How many times do you change y

Asthma __________________

Anemia Do you use toothpaste in brushin

How many times do you visit the

Bleeding Problem ________________________

Heart Ailment

Hypertension

Diabetes

Epilepsy

Kidney Disease

Convulsion

Fainting

DENTAL FINDINGS
Medical History Guide Questions
Yes No Remarks Do you have a toothbrush? Y__

Allergy How many times do you brush yo

How many times do you change y

Asthma __________________

Anemia Do you use toothpaste in brushin

How many times do you visit the

Bleeding Problem ________________________

Heart Ailment

Hypertension

Diabetes

Epilepsy

Kidney Disease

2
2018 SHD Form 2

Convulsion

Fainting

DENTAL FINDINGS
Medical History Guide Questions
Yes No Remarks Do you have a toothbrush? Y__

Allergy How many times do you brush yo

How many times do you change y

Asthma __________________

Anemia Do you use toothpaste in brushin

How many times do you visit the

Bleeding Problem ________________________

Heart Ailment

Hypertension

Diabetes

Epilepsy

Kidney Disease

Convulsion

Fainting

2
2018 SHD Form 2

2
 2018 SHD Form 2

NGS

you have a toothbrush? Y__________ N__________

w many times do you brush your teeth? __________

w many times do you change your toothbrush in a year?

_______________

you use toothpaste in brushing? _________________________________

w many times do you visit the dentist in a year?

_____________________

NGS

you have a toothbrush? Y__________ N__________

w many times do you brush your teeth? __________

w many times do you change your toothbrush in a year?

_______________

you use toothpaste in brushing? _________________________________

w many times do you visit the dentist in a year?

_____________________

2
 2018 SHD Form 2

NGS

you have a toothbrush? Y__________ N__________

w many times do you brush your teeth? __________

w many times do you change your toothbrush in a year?

_______________

you use toothpaste in brushing? _________________________________

w many times do you visit the dentist in a year?

_____________________

2
2018 SHD Form 2