EFTA00134761

BP-A0618

JUN 16

U.S. DEPARTMENT OF JUSTICE

A&O DENTAL EXAMINATION
(Initial Clinical Dental Findings)

<table><thead><tr><th rowspan="2"></th><th colspan="4">Occlusion:</th></tr><tr><th>Oral Hygiene:</th><th>Good</th><th>Fair</th><th>Poor</th></tr></thead><tbody><tr><td rowspan="2">CPITN:</td><td>3</td><td>2</td><td>3</td><td></td></tr><tr><td>3</td><td>2</td><td>3</td><td></td></tr><tr><td colspan="5">Head &amp; Neck / Soft Tissue:</td></tr><tr><td rowspan="2">D: ___ M: ___ F: ___</td><td colspan="4">Classification: CLI</td></tr><tr><td colspan="4">Pain Scale: /10</td></tr></tbody></table>

<table><tr><td colspan="2">Dental Prostheses at Intake:
Yes
Type:
Age:
Condition:</td><td colspan="2">Comments: advanced mood to moderate gingival recession observed. Lower anterior crowding observed</td></tr><tr><td colspan="2">Intra-oral Photos Taken:
Yes
No</td><td colspan="2">Radiographs Taken: (Document findings on A&amp;O encounter)
Yes
No</td></tr><tr><td colspan="4">Instructed how to obtain urgent and non-urgent dental care: Yes √ No:</td></tr><tr><td>Treatment Priorities:</td><td>None:</td><td>Non-urgent:
non-urgent</td><td>Urgent: Referred to Sick Call:</td></tr><tr><td colspan="2">Radiographs authorized:
PAs: ___
BWs: ___
Panorex: ___</td><td colspan="2">Prophylaxis authorized: Yes √ No
(Approval valid 18 months from examination date)</td></tr><tr><td colspan="2">Patient Name:
Epstein, Jeffrey E</td><td colspan="2">Dentist Signature:
C. Ancrum DDS</td></tr><tr><td>Register Number:
76318-054</td><td>Institution:
MCC NEW YORK</td><td>Date:
7-26-19.</td><td>Signature Block/Stamp:
C. Ancrum DDS.</td></tr></table>

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Prescribed by P6400

Replaces BP-A0618 of JUN 10



SDNY_00001018


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