Military Dental Examination Form
Use this form to record a military dental examination, including service member details, dental history, relevant medical background, clinical findings, and follow-up recommendations.
Service Member Information
Full Name
*
First Name
Middle Name
Last Name
Rank
*
Please Select
Private
Private First Class
Corporal
Sergeant
Staff Sergeant
Sergeant First Class
Master Sergeant
First Sergeant
Sergeant Major
Warrant Officer
Second Lieutenant
First Lieutenant
Captain
Major
Lieutenant Colonel
Colonel
General
Other
Service Branch
*
Please Select
Army
Navy
Air Force
Marine Corps
Space Force
Coast Guard
Other
Unit / Command
*
Duty Station / Base
*
Military ID or Service Number
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex / Gender
*
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Dental History and Reason for Visit
Reason for Examination
*
Routine checkup
Pre-deployment
Pain
Emergency
Clearance
Other
Chief Complaint
*
Date of Last Dental Visit
-
Month
-
Day
Year
Date
History of Previous Dental Treatment
None
Fillings
Extractions
Root canal treatment
Crowns/bridges
Braces/orthodontic treatment
Other
Current Oral Symptoms
Dental pain
Swelling
Bleeding gums
Sensitivity to hot/cold
TMJ or jaw pain
Recent oral surgery or procedure
None
Location of Pain or Swelling
Approximate Onset of Current Symptoms
-
Month
-
Day
Year
Date
Details of Recent Oral Surgery or Procedures
Medical Background Relevant to Dental Care
Current medications
Known allergies
Medication
Latex
Other
Significant medical conditions affecting dental care
Heart condition
Diabetes
Bleeding disorder
Asthma
High blood pressure
Immunocompromised condition
Other
Smoking or tobacco use
Never
Former
Current
Other
Pregnancy status
Not applicable
No
Yes
Prefer not to say
Other medical history affecting dental treatment
Oral Health Habits and Current Symptoms
How often do you brush your teeth?
*
Twice daily
Once daily
A few times a week
Rarely
Not at all
Other
How often do you floss?
*
Daily
A few times a week
Rarely
Not at all
Other
Do you use mouthwash?
Yes, daily
Yes, occasionally
No
Other
Do you currently wear any dental appliances?
Dentures
Partial denture
Retainer
Night guard
Mouth guard
Braces or aligner
Other
Current mouth or tooth pain severity
1
2
3
4
5
Location of pain or discomfort
Which symptoms are you experiencing?
Sensitivity to hot
Sensitivity to cold
Sensitivity to sweets
Swelling
Loose teeth
Broken teeth
Sores or ulcers
Difficulty chewing
Difficulty opening mouth
Other
Describe your current symptoms
How long have these symptoms been present?
Have your symptoms changed recently?
Improving
Worsening
Unchanged
Not sure
Other
Clinical Examination Findings and Assessment
Oral Hygiene Status
*
Please Select
Excellent
Good
Fair
Poor
Unsatisfactory
Teeth / Caries Findings
*
No caries detected
Active caries present
Suspected caries
Restorations present
Fractured or worn teeth
Missing teeth
Other findings
Gingival Health
*
Please Select
Healthy
Mild inflammation
Moderate inflammation
Severe inflammation
Bleeding on probing
Other
Periodontal Findings
No periodontal concerns
Gingivitis
Periodontitis suspected
Pocketing present
Mobility present
Furcation involvement
Bone loss suspected
Other findings
Occlusion / Bite Assessment
Please Select
Normal
Mild malocclusion
Moderate malocclusion
Severe malocclusion
Crossbite
Open bite
Deep bite
Other
Missing or Restored Teeth
None
Missing teeth
Restored fillings
Crowns present
Bridges present
Implants present
Dentures or partials present
Other
Oral Lesions / Abnormalities
X-rays / Radiographs
Not taken
Already available and reviewed
Recommended
Required for diagnosis
Periapical
Bitewing
Panoramic
Other
Dental Readiness / Fitness Assessment
*
Not Ready
1
2
3
4
5
6
7
8
9
Fully Ready
10
1 is Not Ready, 10 is Fully Ready
Clinical Impression / Urgency Level
*
Treatment Plan, Follow-up, and Examiner Details
Recommended treatment or referrals
*
Routine cleaning
Fluoride treatment
Fillings
Extraction
Root canal treatment
Periodontal treatment
Specialist referral
Follow-up examination
Observation only
Other
Follow-up timeframe
*
Please Select
Within 1 week
Within 2 weeks
Within 1 month
Within 3 months
As needed
No follow-up required
Restrictions or recommendations
Need for specialist referral
*
Yes
No
Pending evaluation
Next appointment date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Examiner name
*
First Name
Middle Name
Last Name
Examiner title or rank
*
Submit Examination
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