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  1. Surveys
  2. 2014
  3. March
  4. N
  5. Nicaragua Dental Health History
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Exit Survey
 
 
Last Name
   
 
 
 
First Name
   
 
 
 
What is the date?
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is your date of birth?
 
 
 
Have you had problems with any of the following conditions (select all that apply)
 
Bleeding gums
 
Grinding Teeth
 
Periodontal Treatment
 
Clicking or Popping jaw
 
Loose Teeth
 
Broken filings
 
Sores or Growths in your month

 
 
 
How often do you brush your teeth?
 
Never or rarely
 
One to three times per week
 
Once a day or more
 
 
 
Have you had any of the following conditions (select all that apply)
 
HIV Positive
 
AIDS
 
Cancer
 
Hepatitis
 
High Blood Pressure
 
Blood Disease
 
Diabetes
 
Persistant Cough

 
 
 
Blood Pressure (Systolic)
   
 
 
Blood Pressure (Diastolic)