Dntl PBRN Stuy: Rsons or rplmnt or rpr o ntl rstortons Us ts Dt Collton Form wnvr stuy rstorton s rpl or rpr. For nrollmnt n t ollton you my rpl or rpr up to 4 rstortons, on t sm ptnt, urn snl vst. You n o so y lln n t tls on ts normton st n tn lln out rstorton t st or rstorton rplmnt or rpr. For quston, pls nt t nswr tt st ppls y mrkn n X n t orrsponn ox lk ts: X It s vry mportnt tt t rsponss ror wtn t sp llott. Wn rorn numrl rsponss, su s mounts or ts, on numr soul ntr n ox n vry ox soul v numr n t. Tror, t my nssry to ror ln zros wn t numr rqurs wr oxs tn prov. Complt orm soul ml to: Dntl PBRN Coll o Dntstry PO Box 100415 Gnsvll, FL 32610-0415 Vst Dt / / 200 mm y 1. Ptnt Gnr Ml Fml 2. Ptnt n yrs (rmmr: only ptnts 13 yrs ol or olr soul nroll) 3. Ptnt Etnty Hspn or Ltno t Hspn or Ltno 4. Ptnt R Wt Blk or Arn-Amrn Amrn Inn or Alsk Ntv Asn Ntv Hwn or Otr P Islnr Otr (pls spy) 5. Dos t ptnt v ny ntl nsurn or tr prty ovr? Ys P 1 o 5
6. W toot ws trt toy? 7. Bor your trtmnt toy, w toot sur(s) t rstorton nlu? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 8. Wt mtrl ws n t rstorton or you rpr or rpl t toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr Inrt ompost rsn Glss onomr, rsn-mo lss onomr Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton 9. Wt trtmnt you o on ts toot toy? Rpr tv prt o t rstorton Rpl t ntr rstorton Pl tmporry rstorton 10. W rstorton or toot sur(s) you rpr or rpl toy? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 11. Wt mtrl you us or t rstorton or rpr toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr (Brn: ) Inrt ompost rsn Glss onomr, rsn-mo lss onomr (Brn: ) Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton Tmporry rstortv mtrl 12. D you us s, lnn or onn mtrl to pl or rpr t rstorton toy? (Mrk ll tt pply) n Rsn-s onn mtrl Glss onomr, rsn-mo lss onomr Clum yrox-s mnt/lnr Vrns (.. Coplt) (spy) Otr (spy) 13. D you us rur m urn t rstortv prour? Ys 14. D you, or rnt ntst, pl t ornl rstorton tt ws rpl or rpr toy? I t ornl rstorton A rnt ntst t ornl rstorton 15. Wt ws t mn rson or rpr or rplmnt o t rstorton toy? (Coos only on) Sonry/rurrnt rs Entr rstorton s solor Rstorton mrns r solor Rstorton mrns r r or t Bulk rtur o rstorton Rstorton s mssn Toot s rtur Pn or snstvty Ptnt rqust (spy) Otr rson (spy) ANSWER QUESTIONS 16-17 ONLY IF SECONDARY CARIES WAS MARKED IN QUESTION 15 16. Wt tnqu or osrvton l you to t noss o sonry rs? (Mrk ll tt pply) Pron wt ntl xplorr Rorps Intuton or xprn s on lnl pprn Dsolor mrn o t rstorton Frnk or nt rs vtton Prsn o sot, solor ntn or nml An xplortory prprton to nspt t lson 17. Wr ws t lnlly nos sonry rs rltv to t xstn rstorton? (Coos only on) Gnvl to t rstorton wt t rous mrn n t nml Gnvl to t rstorton wt t rous mrn n ntn or mntum Otr loton P 2 o 5
18. W toot ws trt toy? 19. Bor your trtmnt toy, w toot sur(s) t rstorton nlu? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 20. Wt mtrl ws n t rstorton or you rpr or rpl t toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr Inrt ompost rsn Glss onomr, rsn-mo lss onomr Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton 21. Wt trtmnt you o on ts toot toy? Rpr tv prt o t rstorton Rpl t ntr rstorton Pl tmporry rstorton 22. W rstorton or toot sur(s) you rpr or rpl toy? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 23. Wt mtrl you us or t rstorton or rpr toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr (Brn: ) Inrt ompost rsn Glss onomr, rsn-mo lss onomr (Brn: ) Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton Tmporry rstortv mtrl 24. D you us s, lnn or onn mtrl to pl or rpr t rstorton toy? (Mrk ll tt pply) n Rsn-s onn mtrl Glss onomr, rsn-mo lss onomr Clum yrox-s mnt/lnr Vrns (.. Coplt) (spy) Otr (spy) 25. D you us rur m urn t rstortv prour? Ys 26. D you, or rnt ntst, pl t ornl rstorton tt ws rpl or rpr toy? I t ornl rstorton A rnt ntst t ornl rstorton 27. Wt ws t mn rson or rpr or rplmnt o t rstorton toy? (Coos only on) Sonry/rurrnt rs Entr rstorton s solor Rstorton mrns r solor Rstorton mrns r r or t Bulk rtur o rstorton Rstorton s mssn Toot s rtur Pn or snstvty Ptnt rqust (spy) Otr rson (spy) ANSWER QUESTIONS 28-29 ONLY IF SECONDARY CARIES WAS MARKED IN QUESTION 27 28. Wt tnqu or osrvton l you to t noss o sonry rs? (Mrk ll tt pply) Pron wt ntl xplorr Rorps Intuton or xprn s on lnl pprn Dsolor mrn o t rstorton Frnk or nt rs vtton Prsn o sot, solor ntn or nml An xplortory prprton to nspt t lson 29. Wr ws t lnlly nos sonry rs rltv to t xstn rstorton? (Coos only on) Gnvl to t rstorton wt t rous mrn n t nml Gnvl to t rstorton wt t rous mrn n ntn or mntum Otr loton P 3 o 5
30. W toot ws trt toy? 31. Bor your trtmnt toy, w toot sur(s) t rstorton nlu? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 32. Wt mtrl ws n t rstorton or you rpr or rpl t toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr Inrt ompost rsn Glss onomr, rsn-mo lss onomr Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton 33. Wt trtmnt you o on ts toot toy? Rpr tv prt o t rstorton Rpl t ntr rstorton Pl tmporry rstorton 34. W rstorton or toot sur(s) you rpr or rpl toy? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 35. Wt mtrl you us or t rstorton or rpr toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr (Brn: ) Inrt ompost rsn Glss onomr, rsn-mo lss onomr (Brn: ) Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton Tmporry rstortv mtrl 36. D you us s, lnn or onn mtrl to pl or rpr t rstorton toy? (Mrk ll tt pply) n Rsn-s onn mtrl Glss onomr, rsn-mo lss onomr Clum yrox-s mnt/lnr Vrns (.. Coplt) (spy) Otr (spy) 37. D you us rur m urn t rstortv prour? Ys 38. D you, or rnt ntst, pl t ornl rstorton tt ws rpl or rpr toy? I t ornl rstorton A rnt ntst t ornl rstorton 39. Wt ws t mn rson or rpr or rplmnt o t rstorton toy? (Coos only on) Sonry/rurrnt rs Entr rstorton s solor Rstorton mrns r solor Rstorton mrns r r or t Bulk rtur o rstorton Rstorton s mssn Toot s rtur Pn or snstvty Ptnt rqust (spy) Otr rson (spy) ANSWER QUESTIONS 40-41 ONLY IF SECONDARY CARIES WAS MARKED IN QUESTION 39 40. Wt tnqu or osrvton l you to t noss o sonry rs? (Mrk ll tt pply) Pron wt ntl xplorr Rorps Intuton or xprn s on lnl pprn Dsolor mrn o t rstorton Frnk or nt rs vtton Prsn o sot, solor ntn or nml An xplortory prprton to nspt t lson 41. Wr ws t lnlly nos sonry rs rltv to t xstn rstorton? (Coos only on) Gnvl to t rstorton wt t rous mrn n t nml Gnvl to t rstorton wt t rous mrn n ntn or mntum Otr loton P 4 o 5
42. W toot ws trt toy? 43. Bor your trtmnt toy, w toot sur(s) t rstorton nlu? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 44. Wt mtrl ws n t rstorton or you rpr or rpl t toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr Inrt ompost rsn Glss onomr, rsn-mo lss onomr Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton 45. Wt trtmnt you o on ts toot toy? Rpr tv prt o t rstorton Rpl t ntr rstorton Pl tmporry rstorton 46. W rstorton or toot sur(s) you rpr or rpl toy? (Mrk ll tt pply) Olusl or Insl Msl Dstl Bul or Fl Lnul or Pltl 47. Wt mtrl you us or t rstorton or rpr toy? (Mrk ll tt pply) Amlm Compost rsn rtly pl, nlun ompomr (Brn: ) Inrt ompost rsn Glss onomr, rsn-mo lss onomr (Brn: ) Crm or porln Cst ol or ny otr st mtll rstorton Comn mtl/rm rstorton Tmporry rstortv mtrl 48. D you us s, lnn or onn mtrl to pl or rpr t rstorton toy? (Mrk ll tt pply) n Rsn-s onn mtrl Glss onomr, rsn-mo lss onomr Clum yrox-s mnt/lnr Vrns (.. Coplt) (spy) Otr (spy) 49. D you us rur m urn t rstortv prour? Ys 50. D you, or rnt ntst, pl t ornl rstorton tt ws rpl or rpr toy? I t ornl rstorton A rnt ntst t ornl rstorton 51. Wt ws t mn rson or rpr or rplmnt o t rstorton toy? (Coos only on) Sonry/rurrnt rs Entr rstorton s solor Rstorton mrns r solor Rstorton mrns r r or t Bulk rtur o rstorton Rstorton s mssn Toot s rtur Pn or snstvty Ptnt rqust (spy) Otr rson (spy) ANSWER QUESTIONS 52-53 ONLY IF SECONDARY CARIES WAS MARKED IN QUESTION 51 52. Wt tnqu or osrvton l you to t noss o sonry rs? (Mrk ll tt pply) Pron wt ntl xplorr Rorps Intuton or xprn s on lnl pprn Dsolor mrn o t rstorton Frnk or nt rs vtton Prsn o sot, solor ntn or nml An xplortory prprton to nspt t lson 53. Wr ws t lnlly nos sonry rs rltv to t xstn rstorton? (Coos only on) Gnvl to t rstorton wt t rous mrn n t nml Gnvl to t rstorton wt t rous mrn n ntn or mntum Otr loton P 5 o 5