Department of Defense Active Duty/Reserve Forces Dental Examination

Fillable Printable Department of Defense Active Duty/Reserve Forces Dental Examination

Department of Defense Active Duty/Reserve Forces Dental Examination

DD FORM 2813, SEP 2006

DEPARTMENT OF DEFENSE

ACTIVE DUTY/RESERVE FORCES DENTAL EXAMINATION

PREVIOUS EDITION MAY BE USED.

OMB No. 0720-0022

OMB approval expires

Jul 31, 2009

The public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0720-0022). Respondents should be aware that notwithstanding any other provision of

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PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT

AUTHORITY: Public Law 105-85, Sec. 765; DoD Directive

6490.2; E.O. 9397.

PRINCIPAL PURPOSE(S): An assessment by a dentist of the

state of your dental health for the next 12 months is needed to

determine your fitness for prolonged duty without ready access

to dental care.

ROUTINE USE(S): None.

DISCLOSURE: Voluntary; however, failure to provide the

information may result in delays in assessing your dental health

needs for military service.

1. SERVICE MEMBER'S NAME (Last, First, Middle Initial) 2. SOCIAL SECURITY NUMBER 3. BRANCH OF SERVICE

4. UNIT OF ASSIGNMENT 5. UNIT ADDRESS

6. EXAMINATION RESULTS

Dear Doctor,

The individual you are examining is an Active Duty/Guard/Reserve member of the United States Armed Forces. This member

needs your assessment of his/her dental health for worldwide duty. Please mark (X) the block that best describes the condition of

the member, using as a suggested minimum a clinical examination with mirror and probe, and bitewing radiographs. This form is

meant to determine fitness for prolonged duty without ready access to dental care and is

not intended to address the

member's comprehensive dental needs.

(1) Patient has good oral health and is not expected to require dental treatment or reevaluation for 12 months.

(2) Patient has some oral conditions, but you do not expect these conditions to result in dental emergencies within

12 months if not treated (i.e., requires prophylaxis, asymptomatic caries with minimal extension into dentin,

edentulous areas not requiring immediate prosthetic treatment).

(3) Patient has oral conditions that you do expect to result in dental emergencies within 12 months if not treated.

Examples of such conditions are: (X the applicable block or specify in the space provided)

(a) Infections: Acute oral infections, pulpal or periapical pathology, chronic oral infections, or other pathologic

lesions and lesions requiring biopsy or awaiting biopsy report.

(b) Caries/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective

restorations or temporary restorations that patients cannot maintain for 12 months.

communication, or acceptable esthetics.

(d) Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis,

periodontal abscess, progressive mucogingival condition, moderate to heavy subgingival calculus, or

periodontal manifestations of systemic disease or hormonal disturbances.

(e) Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs

or symptoms of pathosis that are recommended for removal.

(f) Other: Temporomandibular disorders or myofascial pain dysfunction requiring active treatment.

(4) If you selected Block (3) above, please circle the condition(s) you identified in this patient if they appear above, or briefly

describe the condition(s) below:

(5) Were X-rays consulted? YES NO

IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)

7. DENTIST'S NAME (Last, First, Middle Initial) 8. DENTIST'S ADDRESS (Street, City, State, 9-digit ZIP Code)

9. DENTIST'S TELEPHONE NUMBER (Include Area Code)

10. DENTIST'S SIGNATURE/STATE LICENSE NUMBER 11. DATE OF EXAMINATION (YYYYMMDD)

FormFlow/Adobe Professional 7.0