Form PC-1790 Report of Dental Examination

PC-OMS-1790 (Dental)

Peace Corps
Report of
Dental Evaluation
PEACE CORPS USE ONLY

Sex M 17 F 17

Name: (Last. F~rst,M~ddleInlt~al)

Social Security number

Date of birth (MO/ D A V / Y R )

Country of service

Date of exam (MO/ DAY / YR)

Cheedr m m

Cl
Cl

Pre-service dental exam
Post-service dental exam
Other (please specify)

HlPAA and Privacy Act Notice:

1 -

1

1

Homefpermanent address

I Telephone No.

(

)

I

The information requested is collected under the authority of the Peace Corps Act, 2 2 U.S.C. 2501 et seq., for the purpose of determining
eligibility of Peace Corps service and of documenting the basis for requested payments. Disclosure of this information is voluntary, but
failure to do so will make i t 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 a t 6 5 Fed. Reg. 53,722 (September 5,2000) and 5 0 Fed. Reg.
1950, 1962 (January 14,1985) regarding the Peace Corps system of records PC-1 7 (Volunteer records). It may also be subject to the
Health Insurance Portability and Accountability Act (HIPAA) and current effective authorizations.

I. General Dental Evaluation
A.

Chart existing restorations, missing
teeth and endodontically treated teeth:

0 Check here if n o existing
restorations, missing teeth
o r endodontically t r e a t e d teeth

C o m m e n t o n findings:

B. Chart diseases, abnormalities and
all recommended treatments:

Cl

C h e c k here if n o disease, abnormality
o r recommended treatment

OR
C o m m e n t o n findings:

-

Paace Corps Report cd DenM Examinabbn

Page I of 4

Applicant SSN:

I. Periodontal Evaluation
A.

Chart periodontal probings, gingival recession, and mobility
Buccal Pocket Depth
Lingual Pocket Depth
Buccal Recession

Lingual Recession

Lingual Recession

Buccal Recession

Lingual Pocket Depth
Buccal Pocket Depth
Calculus Deposits:

B.

O Light

Cl

Moderate

L!

Heavy

identify by number all teeth with:
-

Areas of bleeding upon probing

O

None

Ci

Affected teeth:

Areas of suppuration

Li None

Cl

Affected teeth:

Furcation involvement

u None

O Affected teeth:

None

Insufficient attached gingiva

Ci

-

Affected teeth:

C. Periodontal Classification:

-

No Disease

Class I: Gingivitis

Cl

Class II: Early Periodontitis

Cl
O

Class IV: Advanced Periodontitis

Class Ill: Moderate Periodontitis

D. Recommended periodontal therapy:

Peace Corps. Report af Dental Examination

b.

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MS-1790 Dental (Revised 02/2006)

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Page 2 of 4

Ill. Third Molar Evaluation
A. O
O

No history of pericoronitis
History of pericoronitis
Please provide dates:

B. Q Third molar extraction not recommended
Q Third molar extraction recommended
Please specify recommended extractions:

1% TMJ Evaluation
Ci
Ci

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

V.

Bruxism
O
O

No history of bruxism
History of bruxism
Please describe any bruxism habit, presence of wear facets or needfor occlusal guard:

VI. Prosthesis
O No prosthesis present
O 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 Completed

Signature of Dentist

Page 3 of 4

Applicant SSN:

-

INCOMPLETE FORMS WILL BE RETURNED
AND MAY DELAY PROCESSING!

Dental examination is
complete only when:

,,-F The dentist has completed all sections
r_ of the charting form.

Dentist's signature

2 The dentist has signed and dated the form.

3

Date

The dentist has listed all treatments completed
in Section VII.

Dentist's license number

State

) Applicants only:

The dentist has included one of the
following sets of X-rays:
1)

A full mouth series, or

2)

A Panorex with bitewing X-rays.
Per~apicalor Panorex films must be
less than two years old.
3itewing X-rays must be less than

Dentist's name, address and phone number

II films must be original filrrc
ot duplicates.

>

Close-of-service only:
The dentist has included bitewing X-rays.

FOR PEACE CORPS USE ONLY
Office of Medical Services Dental Consultant

0 Dental Clearance Pending

. Dental Clearance Notes and Recommendations
.

-

-

-

Date
-

Reason for Pending:

13

Dental Clearance

0 Dental Clearance with Restrictions .

Date

-

--

-

--

-

Date

Specify restrictions:

Signature

Peace Corps Report of Denial Examination

Date

a s - 1 1 9 0Dental (Revised OZIZOM)

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