Survey Text

Survey form view entire document:  text  image

e. Is there anyone in the family who has lost all of his or her lower (permanent) natural teeth?

[] Yes
[] No (5)

f. Who is this?
Mark "No lowers" box in person's column.

1[] No lowers

g. Anyone else?

[] Yes (Reask 4f and g)
[] No

Ask for each person with "No lowers" in 4f.
h. Does -- have a lower denture or plate?

1[] Yes
2[] No