Dental Fluorosis Survey

Male Female

Yes No . . Do you have dental fluorosis?

Yes No . . Do you get motion sickness easily?

Yes No . . Do you favor fluoridation?

Yes No . . Do you or did you have sensitive teeth?

Yes No . . Do you have gum disease?

Did you stop using fluoride in toothpaste because it made you sick?

Yes No

If so, in what year did you stop?

Place of birth:

City State

Date of Birth (year)

Current residence:

City State

Occupation

Ethnic origin

White African Asian Hispanic

Native American Other