Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 8
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910. OCCLUSAL RELATIONSHIP
(X Yes or No for each question. If additional space is needed, use the "REMARKS" section.)
YES
NO
ANTERIOR VERTICAL OPEN BITE GREATER THAN 1 mm
ANTERIOR OVERBITE IN EXCESS OF 4 mm
ANTERIOR HORIZONTAL OVERJET IN EXCESS OF 4 mm
SOFT TISSUE IMPINGEMENT OF THE LOWER ANTERIOR TEETH INTO THE HARD PALATE, OR THE UPPER ANTERIOR TEETH INTO THE LOWER
(Describe)
(Bilateral involving more than one tooth)
(Entire quadrant)
11. ORTHODONTICS (X Yes or No for each question.)
PAST HISTORY OF ORTHODONTIC TREATMENT (Date completed)
PRESENTLY UNDERGOING ACTIVE ORTHODONTIC TREATMENT (Specify fixed or removable.) (Is orthodontic surgery required? If Yes, describe.)
WEARING RETAINER APPLIANCES
12. PROSTHODONTICS (X Yes or No for each question. If additional space is needed, use the "REMARKS" section.)
MISSING TEETH (Prosthesis required. Describe.)
MISSING TEETH REPLACED BY AN UNSERVICEABLE PROSTHESIS (Describe)
ARE THERE LESS THAN EIGHT, SERVICEABLE, NATURAL TEETH IN EACH ARCH?
PERIODONTAL
13. PERIODONTAL STATUS (X Yes or No for each question.)
SCREENING
MODERATE TO HEAVY CALCULUS (Supra and/or sub-gingival)
ACUTE NECROTIZING ULCERATIVE GINGIVITIS
LOCAL OR GENERALIZED PERIODONTITIS (With associated bone loss)
LOCALIZED JUVENILE PERIODONTITIS
PERICORONITIS
14. PANOGRAPHIC RADIOGRAPH EXAMINATION (X Yes or No for each question. If additional space is needed, use the "REMARKS" section.)
ABNORMAL RADIOLUCENT/RADIOPAQUE AREA (Describe)
IMPACTED TEETH WITH PATHOLOGY (Describe)
IMPACTED TEETH OTHER THAN THIRD MOLARS (Describe)
OTHER RADIOGRAPHIC ABNORMALITIES (Describe)
15. OTHER ABNORMAL CONDITIONS OF THE ORAL CAVITY NOT PREVIOUSLY MENTIONED (X Yes or No.)
16. REMARKS (Indicate item of reference. Use additional sheet if necessary.)
DODMERB USE
ONLY
DD FORM 2480 (BACK), SEP 2000
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