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pdfNATIONAL SCIENCE FOUNDATION
POLAR DENTAL EXAMINATION
NAME:
DATE OF BIRTH:
DAY TELEPHONE#:
AGE:
EMAIL ADDRESS:
YEAR OF PREVIOUS DEPLOYMENT:
CURRENT DEPLOYMENT DATES: FROM
TO
AFFILIATION:
NSF
S-Event or Group #_______
RPSC
ANTARCTIC DEPLOYMENT STATION:
McMurdo
South Pole
VECO
Other ____________________
ARCTIC DEPLOYMENT STATION:
Palmer
Summit
Field Camp__________________
Alaska
Thule
Other :____________________________
RVIB NB Palmer
RVIB LM Gould
Chart existing restorations, missing teeth and endodontically
treated teeth only:
PERIODONTAL EVALUATION
PROBINGS > 5 mm
YES
NO
ACTIVE DISEASE NOTED
YES
NO
3rd MOLARS PRESENT
YES
NO
POTENTIALLY SYMPTOMATIC
YES
NO
THIRD MOLAR EVALUATION
ALLERGIES:
Documentation of all treatment identified and rendered and original radiographs must accompany this form.
DATES
DIAGNOSES and TREATMENTS
Attach the following ORIGINALS to this exam:
PANO OR FULL MOUTH SERIES
(Required first deployment and every 5 years after)
BITEWING X-RAYS, SET OF 4 MOUNTED
SHOWING ALL POSTERIOR TEETH
(Required annually – within six months of deployment)
*Date of last Pano or Full Mouth Series:________________
I have thoroughly examined this candidate for travel to the Polar Regions. All necessary treatment has been performed; all evaluations
completed; and the appropriate diagnostic radiographs will accompany this completed form as requested by the “Dear Dentist” letter.
_____________________________________
______________________________________________
DENTIST’S NAME (PRINT)
_____________________________________
DENTIST’S SIGNATURE
______________________________________________
TELEPHONE NUMBER (include area code)
ATTENTION EXAMINING DENTIST:
Please forward completed form, all documentation
of treatment and all ORIGINAL X-rays to:
NATIONAL SCIENCE FOUNDATION
ATTN: NSF Medical Director
4201 Wilson Boulevard, Ste 265-S
Arlington, VA 22230
703-292-8124 Fax: 703-292-9001
DATE
ADDRESS
______________________________________________
CITY
STATE
ZIP
MEDICAL STAFF USE ONLY:
PQ
WINTER REVIEW
NPQ
NSF Form 1425-B Page 1 of 1 (APR 2002)
Original plus one copy to: NSF Contractor
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicant: Please retain a copy for your records
File Type | application/pdf |
File Title | NATIONAL SCIENCE FOUNDATION |
Author | Gwendolyn Montez Adams |
File Modified | 2007-09-24 |
File Created | 2007-09-21 |