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Get Ada Medical History Form

Fluoridated? .......................................... Do you drink bottled or filtered water? ........................................... Yes No OK D D D D D D D D D If yes, how often? Circle one: DAILY/ WEEKLY/ OCCASIONALLY 0 Do you have any clicking, popping or discomfort in the jaw? ......... 0 0 Do you brux or grind your teeth? ................................................... 0 Do you have sores or ulcers in your mouth? ................................... D Do you wear dentures or.

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