Form 1425-A Polar Dental Examination

NATIONAL 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:
RAYTHEON POLAR SERVICES COMPANY
ATTN: Medical
7400 S. Tuscon Way
Centennial, CO 80112-3839
1-800-688-8606 ext 32287

DATE

ADDRESS

______________________________________________
CITY

STATE

ZIP

MEDICAL STAFF USE ONLY:
PQ

WINTER REVIEW

NPQ

NSF Form 1425-A 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