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S. Si, depuis quand ?: ???????, Score de Chisholm : ?????????????????? Consommation de Tabac : Oui Non Nombre de cig/jour : ?????????????? Traitement bucco-dentaire actuel ou antérieur proposé

D. De and P. Dentaire, Oui Non Nécessité de réaliser des soins : Oui Non

C. Des-indices-d-'inflammation and . Gingivale-@bullet-présence-de-tartre, Oui Non ? Evaluer les 4 faces des 6 dents et reporter pour chaque dent