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depuis quand ?: ???????, Score de Chisholm : ?????????????????? Consommation de Tabac : Oui Non Nombre de cig/jour : ?????????????? Traitement bucco-dentaire actuel ou antérieur proposé ,
Oui Non Nécessité de réaliser des soins : Oui Non ,
Oui Non ? Evaluer les 4 faces des 6 dents et reporter pour chaque dent ,