Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 7
Download a blank fillable Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Form Approved
DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
REPORT OF DENTAL EXAMINATION
Expires Aug 31, 2003
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports
(0704-0396), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON DRIVE, SUITE 132, USAF
ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,
Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the
Social Security Number (SSN) is used for positive identification of records.
1. NAME OF APPLICANT (Last, First, Middle Initial)
2. SSN OF APPLICANT
INSTRUCTIONS
To be completed at scheduled Examining Center by the Examining Dentist. Panoramic and bitewing radiographs must accompany this
examination and be identified by name and SSN. Expedite completed Dental Examination with completed Medical Examination to:
3. INDICATE ON THE CHART BELOW, RESTORABLE, NON-RESTORABLE, MISSING
4. TYPED OR PRINTED NAME OF EXAMINING DENTIST
TEETH, TEETH REPLACED, SPACES CLOSED AND ANY DEFECTS OR ABNOR-
MALITIES. (Do not chart restorations.)
5. SIGNATURE OF EXAMINING
6. DATE
DENTIST
SIGNED
7. EXAMINING FACILITY
NAME
ADDRESS
RIGHT
NOTE: If examinee has a questionable occlusal
relationship, forward diagnostic casts to:
DODMERB/DB
8034 Edgerton Drive, Suite 132
USAF Academy CO 80840-2200
8. GENERAL
YES
NO
DENTAL CARIES (Indicate on chart, do not chart incipiencies.)
MISSING TEETH, OTHER THAN THIRD MOLARS (Indicate on chart by marking "X" through the roots.)
NON-RESTORABLE TEETH (Indicate on chart by drawing two vertical lines through tooth.)
UNERUPTED TEETH (Draw circle around the tooth on the chart and indicate position by an arrow.)
DEVELOPMENTAL DISTURBANCES IN TEETH (Significant enamel hypoplasias, amelogenesis imperfecta, dentinogenesis imperfecta, etc.)
STAINED TEETH (Intrinsic, unsightly)
9. HISTORY OF ORAL DISEASE, TUMOR OR ANY OTHER ABNORMALITY OF THE ORAL CAVITY (X Yes or No for each question.
If additional space is needed, use "REMARKS" section.)
HAS THE EXAMINEE EVER HAD A CYST OR TUMOR REMOVED FROM THE MOUTH OR JAWS? (If so, describe.)
HISTORY OF ABNORMAL BLEEDING OF THE ORAL TISSUES (Describe)
ORAL ULCERATIONS, SOFT TISSUE LESIONS, ETC. (Describe)
HISTORY OF CLEFT LIP
HISTORY OF CLEFT PALATE
IF YES, IS THERE AN ORO-NASAL OR ORO-ANTRAL FISTULA PRESENT?
(Continued on reverse side)
HISTORY OF TMJ DISEASE OR PAIN (Describe)
DD FORM 2480, SEP 2000
PREVIOUS EDITION IS OBSOLETE.
DoD exception to SF 603 approved by GSA/IRMS 6-86
ADVERTISEMENT
0 votes
Related Articles
Related forms
Dd Form 2489 - Dod Medical Examination Review Board (dodmerb) Farnsworth Lantern And Red/green Color Vision Tests
Medical
Related Categories
Parent category: Business