Dental Fluorosis Survey

Male Female
Yes No . . Do you have dental fluorosis?
Yes No . . Do you get motion sickness easily?
Yes No . . Do you favor fluoridation?
Yes No . . Do you or did you have sensitive teeth?
Yes No . . Do you have gum disease?
Did you stop using fluoride in toothpaste because it made you sick?

Yes No

If so, in what year did you stop?

Place of birth:

City State

Date of Birth (year)
Current residence:

City State


Ethnic origin

White African Asian Hispanic

Native American Other