Dental Health Record Form

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6/9 EXAMPLES

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HEALTH RECORD
DENTAL --Continuation
SECTION III. ATTENDANCE RECORD
15. RESTORATIONS AND TREATMENTS (Completed during service)
16. SUBSEQUENT DISEASES AND ABNORMALITIES
REMARKS
17. SERVICES RENDERED
DATE
DIAGNOSIS-TREATMENT
CLASS
OPERATOR AND DENTAL FACILITY
INITIALS
STANDARD DENTAL FORM 603
DENTAL STANDARD FORM
DENTAL
SECTION 1. DENTAL EXAMINATION
1. PURPOSE OF EXAMINATION
2. TYPE OF EXAM.
3. DENTAL CLASSIFICATION
INITIAL
SEPARATION
OTHER (Specify)
MISSING TEETH AND EXISTING RESTORATIONS
PLACE OF EXAMINATION
SIGNATURE OF DENTIST COMPLETING THIS SECTION
DISEASES, ABNORMALITIES, AND X-RAYS
A.
CALCULUS
SLIGHT
MODERATE
HEAVY
B.
PERIODONTOCLASIA
LOCAL
GENERAL
INCIPIENT
SEVERE
C.
STOMATITIS (Specify)
GINGIVITIS
VINCENT'S
D.
DENTURES NEEDED
(Include dentures needed after indicated extractions)
FULL
PARTIAL
ABNORMALITIES OF OCCLUSION-REMARKS
E.
INDICATE X-RAYS USED IN THIS EXAMINATION
FULL MOUTH
PERIAPICAL
POSTERIOR BITE-WINGS
OTHER (Specify)
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)
IDENTIFICATION NO
PATIENT'S LAST NAME FIRST NAME MIDDLE NAME