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* 1. Age: What is your age on Aug 1, 2018?
For babies less than 1 year old write 0 as the age.

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* 2. Sex: What is your sex? (check one box below)

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* 3. Race: Are you Native Hawaiian? (check one box below)

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* 4. Zip Code (write below)

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* 5. What year was your last dental visit? (write below)

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* 6. How many times a day do you brush your teeth? (write in below)

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* 7. How many times a day do you floss your teeth? (write in below)

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* 8. Do you use mouthwash? (check one below)

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* 9. Do you have any of the following? (Check all that apply)

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* 10. Please rate your overall Oral Health on a scaled from 1 (worst) to 5 (excellent).

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* 11. Can you describe what would help you achieve a higher level for your oral health, or if already excellent, how do you maintain that level. (Please provide comments below)

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