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* 1. Address

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* 2. Date of Birth

Date / Time

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* 3. Did you enroll through Covered California?

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* 4. I brush my teeth

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* 5. I floss my teeth

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* 6. I use a fluoride toothpaste when I brush my teeth

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* 7. I visit my dentist

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* 8. The water I drink is fluoridated.

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* 9. I eat or drink sugary foods (hard or chewy candy, antacids, breath mints, dried fruit, cakes, caramel, soda, energy drinks, juices, non-dairy creamer, flavored yogurt, etc.) or acidic items (citrus fruits, sports drinks, etc.)

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* 10. My gums are puffy, sensitive, and bleed when I brush my teeth and/or I think my gums are receding (shrinking).

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* 11. I have diabetes.

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* 12. I smoke (cigarettes, a pipe, cigars) or I chew tobacco.

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* 13. I am pregnant.

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* 14. I am wearing braces, orthodontic appliances, or partial dentures.

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