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No / DR TV Fl VU DC USAIRKEEP OUT OF REACH OF CHI kapREATIAKEs

CSSUYYY

A -Me'COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

Scantron SystemRev 4/9DENTAL HEALTH QUESTIONNAIRE

Chief Complaint Or Reason For This Examination I

ave ou ver a r ave ou ow (Please Check At The Left OfEach Item)YES NO KNOW

VV

V

Diabetes Seizures

ai ns ign ure

a len s igna ure

a ien s igna ure

a ten igna ure

(Check Each Item)Epilepsy or SeizuresFainting or DizzinessNervousnessStrokeGlaucomaCold Sores (Herpes)Pers! tent CoughEmphysemaTuberculosis / PPD PositiveAsthmaHay FeverSinus ProblemsAnemiaSickle Cell DiseaseG-6PD Deficiency

a Ja e

a e

a e

a e

YES NO KNOW

V

9

V

a e26 Jan 78ponsor s ame

Personal Data Privacy Act of 1974

(Check Each Item)HemophiliaBruise or Bleed EasilyHeart Problems or AnginaHypertensionRheumatic FeverHeart MurmurMitral Valve ProlapseCongenital Heart LesionsHeart SurgeryProsthetic Heart Valve( )PacemakerBlood Transfusion(s)Liver DiseaseYellow JaundiceHepatitis Type

r eniicaon o565531418

LT/ DC/ UND a ure

en a leers igna ure

en a icer s igna ure

en a ice igna ure

Patient I enti 'cation (Use This Space For Mechanical Imprint) a ten s ame (Last First Middle Initial)MANN MICHAEL A

e a Ions [ID o ponsor

YES NO

V

V

V

omponenUSN

BUMEDINST 6600 12

KNOW

1 Have you ever been told that you should not donate blood?2 Have you ever been told that you need antibiotics before dental treatment?3 Females Are you taking birth control pill (BCP )?

Are you or might you be pregnant? (Estimated Delivery)Are you breast feeding at the present time?

4 Do you have a disease condition or problem not listed here?If Yes please describeINSTRUCTIONS Please answer the following questions by circling and if applicable by entering the appropriate response If Yes descnbe If No please write No/None

1 Are You In Flight Statu ? YES NO / Personnel Reliability Program? YES NO2 Are You Presently III Or Under The Care Of A Phy ician? YES NO)

f s Please DescribeH ory Of Hospitalization NO(Including Cancer Treatment)

3 Any Allergie 9 (Including Rubber) NO4' 4Aedications Presently Taking NO

(including Aspirin Etc )Any Family History Of (Circle) Your Social Hi tory Occupation / JobsHeart Dise Cancer Type And Frequency Of

Tobacco Use (Age Started?)Alcohol Con umption

JULa e

UlcersKidney ProblemsSTDDiabetesThyroid DiseaseHIVArthntiPainful Joints (inc Jaw)Prosthetic Joint(s)HivesStenod Medication(s)Drug AddictionAlcohol! mUne;:plained Weight ChangeCancer / Radiation

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a e

a e

(Check Each Item)

SUMMARY OF PERTINENT FINDINGS I RECOMMENDED TREATMENT I MODIFICATIONS (Dentists Use Only)

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rganization350108


THIS PORM IS VOT 4 CONSENTPORM TO REI L 4SL OR USE HEAL. TN CARE INFORMATION PERTAINING TO YOU1 AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN)

Sections 133 1071 87 3012 5031 and 8012 title 10 United States Code and Executive Order 9397

2 PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

This form provides you the advice required by The Privacy Act of 1974 The personal information willfacilitate and document your health care The Social Security Number (SSN) of member or sponsor isrequired to identify and retrieve ilealth care records

3 ROUTINE USES

PRIVACY ACT STATEMENT— HEALTH CARE RECORDS

The primary use ot this information is to provide plan and coordinate health care As prior to enactmentof the Privacy Act other possible uses are to Aid in preventive health and communicable disease controlprograms and report medical conditions required by law to federal state and local agencies compilestatistical data conduct research teach determine suitability of persons for service or assignments adjudi-cate claims and determine benefits other lawful purposes including law enforcement and litigation conduct authorized investigations evaluate care rendered determine professional certification and hospitalaccreditation provide physical qualifications of patients to agencies of federal state or local government upon request in the pursuit of their official duties

4 WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDINGINFORMATION

In the case of military personnel the requested information is mandatory because of the need to documentall active duty medical incidents in view of future rights and benefits In the case of all other personnel/beneficiaries the requested information is voluntary If the requested information is not furnished compre-hensive health care may not be possible but CARE WILL NOT BE DENIED

This all inclusive Privacy Act Statement will apply to all requests for personal information made by healthcare treatment personnel or for medical/dental treatment purposes and will become a permanent part ofyour health care record

Your signature merely acknowledges that you have been advised of the foregoing If requested a copy ofthis form will be furnished to you

SIGNATURE OF PATIENT OR SPONSOR

FORM 91 FEB 76

SSN OF MEMBER OR SPONSOR DATE

6'53PREVIOUS EDITION IS OBSOLETE S/N 0102 LF 002 0051

US Government Printing Office 1995— 604-085/22140


CURRENT STATUS mci itovertheoIDATE FORM PLACED IN US

Box 1 Accession and Subsequent Diseases and AbnormalitiesPENCIL ENTRIES ONLY

A BCDE F GHIJ

S

2 3 7 5 5 10 II 12 13 14 5 15

32 31 30 25 20 V as 25 24 as 22 21 xe 15 to 17

This f is ded to remain in effect for the members entire Ice career Ifs form is

A A A A A

BR DP ONEIL K

A BCDE F GIN IJ

enzturriS [cal alert box on the new form is correctDATr:JORM LAC

Box 2 Missing Teeth at Time Of Accession andTreatments Completed After Accession B CK INK ENTRIES ONLY

2 3 5 0 5 5 10 11 12 13 14 115

32 at 20 20 35 27 n n 24 n n xi 35 19 10 17

.......1 A n1 a—a 1 A A A

sa (IP oN U L

Box 3 If medical alert exists write RT- n large red letters followed by short explanation.

ett.

Box 4 s Last Name First name MI Patient/Sponsor Social Security Number—MAN-14 PilICHAE-I: ANTHONY M C350565-5_5-1418 1 26 slAN 78 YYY

Enclosure (4.)31410GL


Ian - r'ENTAL EXAMINATION 'dBUMEDApproved Dental Exam Form Ver 3 (trial)

(Cont Do NOT remove this documentfrom the dentalrecord

Sequence Treatment Need Data EntryPhase Department Phase 1 (Urgent) Phase 2 (Routine) Phase 1 Phase 2

PSR ScoreHygiene/Prophy RDH (1) DT (2) 60(3)Operative(Teeth)

Oral Surgery 1(Teeth) Simple 32

Complex3 32

Periodontics Sextants 1 2 3 4 5 6(Sextants with a PSR Score of 3 4 or*

Endodontics(Teeth) Anterior

.. ,.. ....

Posterior

Prosthodontics(Teeth) Fixed

Removable

Oral DiagnosisSealants(Teeth)

Appointment Schedule Amendments to original planDay Date Room Time Duration Name Date Dept Comp/GD

\

Notes

Recall RecallDate Interval 12 Months

Technician s DentalInitials Class 1 2

Date

Namestamp

Patients Last name First name MIMANN MICHAEL ANfHONY M C3505b5-.53-,14i8 li 26 JAN 7a

JUL 1 1 u96

LT IND R

YVY ,

SSN(patient/sponsor)

Date

Namestamp

Tobacco Cessation

Oral DiseaseCounselingTMD Eval

Medical Eval

Refer to Dental Treatment Special Eva!Form/SF 603A for amendments

Patient has been advised of the findings of this Treatment completed and T2 examexamination and the treatment plan performed this dateExaminers signature Examiners signature

*U o Governme t P nt ng Off ce 1996-747 212/08360

31173 GL

123

RDH (1)

456

\T (2 D 0(3)

3 41 2 3

11 2

33

i 1 2 3 1 3456 4 5 6789 7 8 9

16 1 16 1 2 3 1 2 317 32 17 4 cr5 6 4 5 6

1 1 3 1 317 456 5 6

1 2 3 4 5 6 1 2 3 1 2 3) Highest PSR Score 1 23 4 5 6 4 5 6

2 3 1 2 3

1 2 3 1 2 3-2-3 — 3

4 5 6... ...

4 5 6

1 2 1 21 1

123 1 2 3456 4 5 6ecommen e or


en a xa inz InReason for Examination Auuession PeriodicChief Complaint None

Type of Exam i 2 Blood Pressure HQ datedjuL 11 1996 ReviewedHQR Findings None significant

2

9F b 10G

18

25P 26Q

PSR ScoreModifiedFull

Remarks

3rd molar findln s

Normal EruptionImpactionPartial EruptionCommunicationPurulenceSymptomsinflammation

5

As-sessme of. Chief Complaint

Canes RiskPeno RiskEndo Assessment

3

4

3

11H

19

Radiographs Ordered BWs Pano PAs #Radiographic findings (except canes) None significant

Canes, defective restorations & fractured teeth (radiographic & clinical)

1 16 17 3

4A

121

20K

' enodontalCondition

Canes diagnosis See Objective findings

Canes Risk FactorsDMFT Score 1Fluoride exposures/dayExposed root surfaces

Endo & Other ClinicalFindings

rs

HealthGingivitisLJPEarly OnsetAdult Perio

Other

27R 28S

OCS/Soft Tissue findings

NodesBuccal MucosaPalateFloor of Mouth

Remarks

TMD Findings None significant

Oral Sur e1 16 17 32

Pencoronrtis

I sufficient a ohlength

Non restorabl

Non-f nct cnal

BUMEDApp wed Dental Exam Form Vet 3 (trial)Do NOT remove this document from th dentalrecord

Other

LipsOro pharynxTongueVestibules

5B 60 7D 8E

13J 14 15

21L 22M 23N 240

29T 30 31


Tooth

31412 GL

DateMafiosi Aloft

0

DENTAL TREATMENT

MANN MICHAEL ANTHONY M -C$50585,-53418 ii. JAN 78 YYY1

US GOVERNMENT PRINTING OFFICE J747 634-1996

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pa eon a

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DentalClass

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ViCe.gW-74:77.4 "

Enclosure (3)COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

Tooth

31412 GL

DateMedical Alert DENTAL TREAMENT Dental

Class


Tooth

31412 GL

Date

1 3 1991

Medical AlertDENTAL TREATMENT

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Pt inf ,k1 sisp SHOW

ORAL SURGERY EVAS T 3 exam PCI HQR dtd

MEDS 0ALLERGIESHabits I Other

0 BP Age IP:8.--- rxclloOCSE: tfi_fuL. TIWS fyot eng

A

P di /1Pt inf of Tx needs Alt Tx Prognosis

all Pt Questions Pt gives inf consent

MANN MICHAEL- ANITHIJIIY N - C3505(J5-53-14,1,8 ii 2b JAN 78 Yre

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US GOVERNMENT PRINTING OFFICE J747 634-1996

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DentalClass

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DateMedical Alert

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DENTAL TREAT IvIENT

MA- NN MICHAEL, ANTHUNY565-53,018 11 26 JAN 78

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• ORE.ISIC E MINATIa,EXISTING RESTORATIONS EXISTING TE , MISSING TE , PROSTH CAPP NCES AND VA TION OF NORMAL CONDITIONS (NON-DISEASE) AS OF

LEAL F RLT / DC/ USNNDOGREATLAKES

A B C D E F G H I J

1

cri V . , sod 1....t I

%

1 2 3 4 5 6 7 8 6 10 11 12 13 14 15 16

32 31 30 22 28 27 26 25 24 23 fl 21 20 12 17

A A A A

T S R a P 0 N M L K

R MARKS SOFT TISSUE0 *)

LEUKOEDEPAA

MELANOP .....

AMALGAM TATTOO

OTHER:

OCCLUSION HARD TISSUE

ANGLE'S C S

OVERJET tvl

OVERBITE I f/1 TORI

CROSSBITE ROTATED TEETH

REMARKS MA SED TE

OTHER

MANN MICHAEL, ANTHUNY M C3501565-53-14i8 11 46 JAN 78 YYY

JUL • 1 1996

I NSIC STAINING CYCUNE

Patient Last Name F rat Nam. MI Patient Social SocuMy Number31411 GL

U GOVERNMENT PRINTING OFFICE 747 633-1996

ate

Enclosure taCOPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

_ _ 14 C350;-14A-1\iN MICHAEL ANTHONY5b5-56-1418 11 2 E) JAN 78 YYY


MANN 1,4ICHAELk ANTHONY NI C350565m53-?1418 11 Et) AN 78 YYY


_

MANN MICHAEL, ANTHuNY M cs505b5-5.5.,144,8 U 2b JAN 78 YYY


MANN MICHAEL ANTHONYI 545-53”1418 11 ab JAN 78vi C350

YYY


-MA-1414 kCHAEL, ANTHONY- M C,50156S-53.'1418 26 JAN 7 0 YrY


ORANDUM

From. SemorM cal Officer Branch M cal Cl c 237To Personnel Support Detac ent

Subs HIV S G PRIOR TO S TION OM ITARY SERVICE

1i 14.4.4embers "1,T; 'a. doc--entat-A HP.VI test ivvi44--- 90 Anyys of separation. "Pls.1111,

results from the test drawn tor

N e t, F Oil AN AlicitA6 L. A SSN s 5 3 7 18on/q jAvii 77 (date HIV drawn) are not available at this eM ber has been found fit for aration

2 M ber been i fo _ed t t his medical record will be closed in abcentia, as indicated byIns/her si ture below

Member's Si ture Date Z. I J q7tut,

3 info...zition requir.ed pomt 4nnofcont A.U11/411.1.1.1111 ally 1111 ft'sders (It extension .5.564

Z

Date Zi AIN'


MEMO NDUM

From LCPO/LPO Physical Examination Section EMC 237

To -A nil IC HAE 5 65- 3Member's Name Last First M I SSN

Subj HIV SCREENING PRIOR TO SEPA TION FROM MILITARY SERVICE

1 You are required to have a documented HIV test within 90 daysof your separation The results from the test drawn J A)?(date HIV drawn) are not available at this time You have in allother regards been found fit for separation

2 Your medical record will be closed in absentia after theseresults are received and your records will be forwarded for finaldisposition at that time A copy of your physical examinationStandard Form 88 and history Standard Form 93 with your HIVresults documented will be forwarded to you at the address you haveprovided below

MEMBER'S MAILING DRESS FOR HIV RESULTS

r770 1Street Address 101 V LLE -r City Ul301enistate PA Zip Code

(.7 1 7 ) 3 - O-7 q 2_Area Code Telephone Number

0

Member's Sicrat,..1.=

--r

Date

2A 97Date

3 If you have any questions, please contact HM1 Black at (847) 688-5564

HM1 lack


copy made by varmc, st. louis from a record in … · jul ae ulcers kidneyproblems std diabetes...

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