Registration of ESS
 
Help us to know you better
 
*Name :
     
*Age :
     
*Sex :
     
*Email ID :
     
*Contact No. :
     
Address :
     
Questions : 1 ]  Do you have missing teeth?
   
     
           If yes, are you i) partial edentulous ii) total edentulous?
   
     
    2 ]  How did you loose your tooth/teeth?
          i) Age
         ii)  Dental Caries  
        iii) Accident
        iv)  Gum Diesease
         v)  Others (please spacify)
       
     
    3 ]  Do you wear denture?
   

     
          If Yes, fixed or removable and are you confortable with existing denture?
          
     
         If not,denture, do you wear bridges or implant?
         

     
    4 ] Are you aware of Health and consequences of missing teeth?
   

     
    5 ] What are the problems you face due to missing teeth?
          
     
   
     
 
   
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