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Dental Health Record Form Example

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Text in this example:

HEALTH RECORD DENTAL --Continuation SECTION III. ATTENDANCE RECORD 15. RESTORATIONS AND TREATMENTS (Completed during service) 16. SUBSEQUENT DISEASES AND ABNORMALITIES REMARKS REMARKS 17. SERVICES RENDERED DATE DIAGNOSIS-TREATMENT CLASS OPERATOR AND DENTAL FACILITY INITIALS STANDARD DENTAL FORM 603 DENTAL STANDARD FORM HEALTH RECORD DENTAL SECTION 1. DENTAL EXAMINATION 1. PURPOSE OF EXAMINATION 2. TYPE OF EXAM. 3. DENTAL CLASSIFICATION INITIAL SEPARATION OTHER (Specify) 1 2 3 4 1 2 3 4 5 4. MISSING TEETH AND EXISTING RESTORATIONS REMARKS PLACE OF EXAMINATION
DATE SIGNATURE OF DENTIST COMPLETING THIS SECTION
5. DISEASES, ABNORMALITIES, AND X-RAYS A. CALCULUS SLIGHT MODERATE HEAVY B. PERIODONTOCLASIA LOCAL GENERAL INCIPIENT MODERATE SEVERE C. STOMATITIS (Specify)
GINGIVITIS VINCENT'S D. DENTURES NEEDED
(Include dentures needed after indicated extractions) FULL PARTIAL U L U L ABNORMALITIES OF OCCLUSION-REMARKS E. INDICATE X-RAYS USED IN THIS EXAMINATION FULL MOUTH
PERIAPICAL POSTERIOR BITE-WINGS OTHER (Specify) DATE
PLACE OF EXAMINATION SIGNATURE OF DENTIST COMPLETING THIS SECTION
SECTION II. PATIENT DATA 6. SEX
7. RACE
8. GRADE, RATING, OR POSITION 9. ORGANIZATION UNIT 10. COMPONENT OR BRANCH 11. SERVICE, DEPT., OR AGENCY 12. PATIENT'S LAST NAME-FIRST NAME-MIDDLE NAME
13. DATE OF BIRTH (DAY-MONTH-YEAR) 14. IDENTIFICATION NO. (AFSN/SSAN) DENTAL STANDARD FORM IDENTIFICATION NO PATIENT'S LAST NAME FIRST NAME MIDDLE NAME

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