DHP 2021-22 Catalog

EXAMINATION RECORDS

EXAMINATION RECORD

Birthdate

Name

Examination Date

Medical Alerts

Account Number

CLINICAL DATA General condition of teeth Plaque

Stains

Abrasions

Condition of present restorations Overhangs Condition of the floor of mouth Palate: Hard Soft

Contact points

Cheeks

Lips

Frenum

Tongue

Ridges

Calculus: Slight

Moderate

Excessive

Oral cancer exam

TMJ

Neck

Occlusion

FORMS

Tooth

Services necessary

Fees

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

X-rays Date Diagnostic Models Date Photograph Clinical Exam Vitality Test Blood Pressure

Health Alerts

Totals

Dental Health Products, Inc. • 800-626-2163 • Form #792- 1057

Front

Exam Form 792-1057.indd 1

3/28/11 10:52 AM

Name

Address to send statements to

Zip

Daytime phone

Tooth No.

Date

Service rendered

Insurance

Charges Payments Balance

Examination Record (Clinical Data) Form 8-½" x 11" form, printed on 80# white paper with black ink. Shrink wrapped in 100 sheets per package. 792-1057 Each .................................... $15.25

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