OMB No. 0990-0324; OMB Approval Expires 05/31/2020
Department of Health and Human Services
Public Health Service Commissioned Corps
REPORT OF DENTAL EXAMINATION OF APPLICANTS TO THE
PUBLIC HEALTH SERVICE COMMISSIONED CORPS
(See Privacy Act Statement for Form PHS-6355)
NAME (Last, First, Middle) (Please type or print) SOCIAL SECURITY NUMBER
INSTRUCTIONS TO APPLICANT
Present this form to your examining dentist for completion. Failure by you or your examiner to comply completely will delay
medical clearance, which is required prior to call to active duty. You may be able to obtain a dental examination at dental
examination sections of military medical facilities. If done privately, it must be done at your own expense.
INSTRUCTIONS TO EXAMINING DENTIST
A complete examination is required in order that all questions listed below can be completed. If there are a number of "Yes"
responses to questions listed below, or if otherwise clinically indicated, bitewing and panoramic (or diagnostic quality full
mouth) radiographs should be performed. If examinee has a questionable occlusal relationship, forward diagnostic casts to
the address at the end of this form.
(1)
Indicate on the chart below restorable teeth with an "R," non-restorable teeth with an "N," missing teeth with an "X," teeth
replaced by a fixed or removable prosthetics by a "continuous line," and any other defects or abnormalities. Do not chart
restorations.
RIGHT
1 2 3 4 5 6 7 8 9
10
11 12 13
14 15 16
LEFT
171819
202122232425262728
29
303132
(2)
GENERAL
(Check Yes or No for each question)
Yes No
b. MISSING TEETH, OTHER THAN THIRD MOLARS (Indicate on chart by marking "X" through the roots)
c. NON-RESTORABLE TEETH (Indicate on chart by marking "N" through tooth)
d. UNERUPTED TEETH (Indicate by marking "U" in the position on the tooth)
e. DEVELOPMENTAL DISTURBANCES IN TEETH (Significant enamel hypoplasias, amelogenesis imperfecta, dentinogenesis imperfecta, etc.)
f. STAINED TEETH (Instrisic) (unsightly)
a. DENTAL CARIES (Indicate on chart, do not chart incipiencies)
(3) HISTORY OR ORAL DISEASE, TUMOR OR ANY OTHER ABNORMALITY OF THE ORAL CAVITY
(Check Yes or No for each question. If additional space is needed use "REMARKS" section)
Yes No
a. HAS THE EXAMINEE EVER HAD A CYST OR TUMOR REMOVED FROM THE MOUTH OR JAWS (If so, describe)
b. HISTORY OF ABNORMAL BLEEDING OF THE ORAL TISSUES (Describe)
c. ORAL ULCERATIONS, SOFT TISSUE LESIONS, ETC. (Describe)
d. HISTORY OF CLEFT LIP
e. HISTORY OF CLEFT PALATE
(1) If yes, is there an oro-nasal or oro-antral fistula present?
f. HISTORY OF TMJ DISEASE OR PAIN (Describe)
PHS-6355 (Rev. 05/17)
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