Student Namo Medical History formation] Periodontal Gpge Type ; Date jeaione | OHI CiyAel cod 0 Adv Patient Nar fief Chronic Aggressive _ eT ia eerie hee 5a Tat (12-88) 1 Goviati (60% yoars) Part Medical [Oral | Gharing ] GH] Treatment | Asopsie | Profeesio- | Poms] Pomte% | X26 Parl History Exam 10 6 Plan/Eval 5 nalism Total Score 6 10 of pttx 10 50 z 5 | 4. t tt Pan Number of | Poteh | Namberof [Supra] Numbar gi SubScore | Tissue [Percant | s4a@a | X75] PartiSaore ‘rots’ | Seore_| “sugds)| seare | "sy 2) Trume_|_ ‘Totals ae St eS (e0 F Loe DO = ct Gong mince see CRA GLI feu ‘Student Signature: ima Radlographe Mado! 0 BWe 0 Vert BWe ~o Povlapleale) Polishing Proficiencies completed: tS PrPraAce Ct J Supra Cale Pyles ook Flt. Vartughy ‘Sub Cale \ 5. sioicsslcn ales Stakred items must be earned or student receives a “0” for daily patient” Tissue Trauma a cater ~\ Huasora -7 2reisorn Patient Instruction: 1. Sequence of troat 2, Time management 9. Professional appearance 10. Operatory organization