,4

Name: (Last, First, Middle Initial) Sex M 0 F 0

Social Security number Date of birth (MO/DAY /YR)

Country of service Date of exam (MO/DAY/YR)

Home/permanent address

HIPAA and Privacy Act Notice: I Telephone No. ( ) I

The information requested is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq., for the purposes
of documenting the basis for requested payments. Disclosure of this information is voluntary, but failure to do so will make it
impossible for the Peace Corps to pay for these services. This information may be used for the routine uses described in the
Privacy Act, 5 USC 552a, and in the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 Fed. Reg. 1950, 1962
(January 14, 1985) regarding Peace Corps system of records PC-17 (volunteer records). It may also be subject to the Health
Insurance Portability and Accountability Act (HIPM).

I. General Dental Evaluation

A. Chart existing restorations, missing ... .r

teeth and endodontically treated teeth:

0 Check here if no existing

restorations, missing teeth
or endodontically treated teeth ..,..;~
,
32$ 2
31
:3
30
5 6 7 8 9 10 11 12
tv
13
- 14 15 16 r-
m
OR 29 28 27 26 25 24 23 22 21 20 19 16 17 ~

Comment on findings:
B. Chart diseases, abnormalities and
-L -..

J
u

all recommended treatment: >-

0 Check here if no disease, abnormality

or recommended treatment

OR

Comment on findings:
"~~

Peace CorpS' Report of Dental Examination PG-1790 Dental (O7/2005)

-~
 Appllcam ~~N:

II Periodontal Evaluation
A. Chart periodontal probings, gingival recession, and mobility

Buccal

Lingual

Buccal
~
ff

Lingua)

Lingual

§
Buccal

Lingual
Buccal

Calculus Deposits: 0 Light 0 Moderate 0 Heavy

B- InAntif~ h~ nllmhAr ~II tAAth with. ..

Areas of bleeding upon probing 0 None 0 Affected teeth:

Areas of suppuration 0 None 0 Affected teeth:

Furcation involvement 0 None 0 Affected teeth

Insufficient attached gingiva 0 None 0 Affected teeth

..
0 No Disease 0 Class I: Gingivitis
0 Class II: Early Periodontitis
0 Class III: Moderate Periodontitis
0 Class IV: Advanced Periodontitis

D- RA~nmmAnrlArl pArindnnt~1 thAr~p¥~ .

Page 20f 4
 Applicp-.
SSN:I"==~ ~

III. Third Molar Evaluation

D No history of pericoronitis 0 Third molar extraction not recommended
D History of pericoronitis 0 Third molar extraction recommended
Please provide dates: Please specify recommended extractions:

IV. TM~ Evaluation

[:) No history of TMD
[:) History of TMD Symptoms
Please describe treatment provided, dates, and if symptoms are present at this time:

V. Bruxism
Q No history of bruxism
Q History of bruxism
Please describe any bruxism habit, presence of wear facets or need for occlusal guard:

VI. Prosthesis
Q No prosthesis present
Q Prosthesis present
Please describe the nature and extent of the prosthesis (e.g. full or partial dentures, bridge, etc.)
and the need for repair or replacement:

VII. Treatment
List all treatment completed after this examination. Do not include treatment planned but not yet completed.

Treatment Date Signature

 Applicant SSN:

FOR PEACE CORPS USE ONLY)I.-

Office of Medical Services Dental Consultant. Dental Clearance Notes and Recommendations

n nental Clearacce E?:enrling n~t~

Reason for Pending:

0 Dectal CIear~n~A n~tA

0 Dectal CJeara..~withBestrictinn~ n~t~

Specify restrictions:

PeaceCorps' Report of Dental examination -1790 Dental (07/2005) Page 4 of 4