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N/A
No DNIF issued
DNIF YES; Verbal for 8 hours due local anesthetic administration
DNIF YES; AF1418 Generated and sent to FSO due to:
FLY
N/A
NO
YES Notify CMA
PRP
N/A
NO
YES
ARMS
Pain
Physical chart is present
Physical chart is not present
Chart is hand carried
Chart
Initial (Comprehensive)
Periodic
Deployment
Separation
Retirement
Overseas Clearance
Flight Physical
Limited
Exam Type
N/A
Examination and treatment completed within 90 days of seperation
Examination and treatment completed within 90 days of retirement
Treatment cannot be completed prior to separation
Treatment cannot be completed prior to retirement
Sep/Ret
Chief Concern
BP (Sys)
BP (Dia)
Within Normal Limits
>= 140/90 - Verbal Referral to PCM
>= 160/100 - Consult Initiated
BP Eval
Temp
Medical History Reviewed
Med Hx
Medication Reconciliation Completed
Meds Rec
Instrument Sterilization Verified
Instruments
Assistant
Resident Supervisor
Radiographs Captured
Radiographs Captured, Previous Radiographs Reviewed
No Radiographs Captured, Previous Radiographs Reviewed
Visual Exam Only
Radiograph(s)
BW XR Date
Pano XR Date
Peri XR Date
FMX XR Date
Other XR's'
BW's captured
Pano's captured
Peri's captured
FMX taken
0
1
2
3
4
1*
2*
3*
4*
PSR UR
0
1
2
3
4
1*
2*
3*
4*
PSR LR
0
1
2
3
4
1*
2*
3*
4*
PSR UM
0
1
2
3
4
1*
2*
3*
4*
PSR LM
0
1
2
3
4
1*
2*
3*
4*
PSR UL
0
1
2
3
4
1*
2*
3*
4*
PSR LL
Head Neck / Oral Cancer Screening
Radiographic Findings
Clinical Findings
Low
Moderate
High
Caries Risk
No tobacco / vape use
Smoking
Smokeless Tobacco
Smoking and Smokeless
Vape Usage
Smoke
5% F Varnish
Pt Declines
None Recommended
F Rx at Pro
N/A
Pt Accepts
Pt Declines
HCR Program
Prescriptions
Treatment Plan
Findings Reviewed / Pt Accepts Tx Plan
Pt Consent
Contact Information Updated
Contact
Disposition
Rx Selector
Prevident 5000 Plus. Disp: 1 Tube. Sig: Brush with pea size amount and expectorate, do not rinse; repeat every night for 6 months. 2 refills. Com Meds Rec. ROMD
Clinpro 5000. Disp: 1 Tube. Sig: Brush with pea size amount and expectorate, do not rinse; repeat every night for 6 months. 2 refills. Com Meds Rec. ROMD
Chlorhexidine 0.12%, Disp: 1 bottle 473 mL. Sig: 10ml rinse for one minute daily for one week every month for 6 mo. 0 refill. Com Meds Rec. ROMD
Amoxicillin 500 mg. Disp: 20 tablets. Sig: Take 4 tablets (2 g) 1 hour before procedure. 0 refill. Modified Meds Rec com. ROMD
Tx Selector
Treatment Complete
Prophy
High Caries Risk Program:
Operative for:
OS Eval for:
Pros Eval for:
Perio Eval for:
Perio Maint q3 Months:
Perio Maint q4 Months:
Perio Maint q6 Months:
Endo Eval for:
Tooth Selector
-
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
#17
#18
#19
#20
#21
#22
#23
#24
#25
#26
#27
#28
#29
#30
#31
#32
#A
#B
#C
#D
#E
#F
#G
#H
#I
#J
#K
#L
#M
#N
#O
#P
#Q
#R
#S
#T
Tooth Status
Missing
Unerupted
Defective Restoration
Retained Primary
Impacted
Supernumerary
Fractured Cusp
Tooth Fracture (Ellis Class I)
Tooth Fracture (Ellis Class II)
Tooth Fracture (Ellis Class III)
Split Tooth
Vertical Root Fracture
Mobility Class 0
Mobility Class 1
Mobility Class 2
Mobility Class 3
Prosthodontics
PFM Crown
Cerec Crown
Stainless Steel Crown
Full Gold Crown
Fixed Partial Denture
Implant
Veneer
Inlay
Onlay
Surfaces
M
O
I
D
F
B
L
Caries
No Caries Noted
Incipient Caries
Caries
Recurrent Caries
Pulpal Dx
Normal Pulp
Reversible Pulpitis
Symptomatic Irreversible Pulpitis
Asymptomatic Irreversible Pulpitis
Pulp Necrosis
Previously Treated
Periapical Dx
Normal Apical Tissues
Symptomatic Apical Periodontitis
Asymptomatic Apical Periodontitis
Acute Apical Abscess
Chronic Apical Abscess
Condensing Osteitis
Preview
Commit Current Entry to Target
Findings Target
Radiographic Findings
Clinical Findings
Prescriptions
Treatment Plan
Disposition