EFTA00134761¶
BP-A0618¶
JUN 16¶
U.S. DEPARTMENT OF JUSTICE¶
A&O DENTAL EXAMINATION (Initial Clinical Dental Findings)¶
| Occlusion: | ||||
|---|---|---|---|---|
| Oral Hygiene: | Good | Fair | Poor | |
| CPITN: | 3 | 2 | 3 | |
| 3 | 2 | 3 | ||
| Head & Neck / Soft Tissue: | ||||
| D: ___ M: ___ F: ___ | Classification: CLI | |||
| Pain Scale: /10 | ||||
| Dental Prostheses at Intake: Yes Type: Age: Condition: | Comments: advanced mood to moderate gingival recession observed. Lower anterior crowding observed | ||
| Intra-oral Photos Taken: Yes No | Radiographs Taken: (Document findings on A&O encounter) Yes No | ||
| Instructed how to obtain urgent and non-urgent dental care: Yes √ No: | |||
| Treatment Priorities: | None: | Non-urgent: non-urgent | Urgent: Referred to Sick Call: |
| Radiographs authorized: PAs: ___ BWs: ___ Panorex: ___ | Prophylaxis authorized: Yes √ No (Approval valid 18 months from examination date) | ||
| Patient Name: Epstein, Jeffrey E | Dentist Signature: C. Ancrum DDS | ||
| Register Number: 76318-054 | Institution: MCC NEW YORK | Date: 7-26-19. | Signature Block/Stamp: C. Ancrum DDS. |
PDF¶
Prescribed by P6400¶
Replaces BP-A0618 of JUN 10¶
SDNY_00001018¶
| EFTA_00000227 | | :--- | :--- |¶
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