Removable Partial Denture
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Date
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Patient Code No *
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Patient name
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Age
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Nationality
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Tribe
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Gender
Phone number
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Occupation
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Residence
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Habits
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Dental history :
How long have you been without teeth ?
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Reasons for the loss of teeth
a) Chief complaint
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b) Expectations
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c) Denture experience
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How long have you worn denture ?
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How many dentures have you had ?
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Age of the present denture
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Denture worn
How did you get along with your previous dentures
Why do you need new dentures?
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Medical history :
Patient's general look
Use of any medications
Type
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Have you had surgery or radiation ?
Have you had any of the followings ?
Others
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