A&O Dental Examination

• Legal Form Number: BP-A0618
• Date: 2016-06
• Year: 2016
• Section: Federal Bureau of Prisons

BP-A0618 A&O DENTAL EXAMINATION

JUN 16 (Initial Clinical Dental Findings)

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Dental Prostheses at Intake:

Yes

No

Type:

Age:

Condition:

Comments:

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:

Urgent: Referred to Sick Call:

Radiographs authorized:

PAs:

BWs:

Panorex:

Prophylaxis authorized: Yes No

(Approval valid 18 months from examination date)

Patient Name:

Dentist Signature:

Register Number:

Institution:

Date:

Signature Block/Stamp:

PDF Prescribed by P6400 Replaces BP-A0618 of JUN 10

Oral Hygiene:

Good

Fair

Poor

CPITN:

Head & Neck / Soft Tissue:

D: .

M: .

F: .

Classification:

Pain Scale:

/10