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    36 views5 pages

    Dental Examination Form

    Uploaded by

    olaogun

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    S VSO dental examination form \VSO placements are mainly in rural areas of developing countries where volunteers will not have easy access toreliable dental services. As.a result preventative care regimes are impossible to arrange and volunteers are unable to have any form of regular follow-up such as 3-monthly hygienist visits or 6-monthly checkups. For this reason we ask volunteers to attend their regular dentist for a dental check-up approximately three months before their departure date. Any necessary work/treatment should be identified at this vist and carried out before the volunteer leaves the UK to ensure that there will be no foreseeable dental problems during their placement. We recognise that the form is detailed and we would be grateful if you could provide as much information as possible. The information you provide will be 2 useful reference tool should the volunteer experience any problems during their placement. Please nate that VSO will only the cost of emergency dental work (work required to give symptomatic relief) while volunteers are ‘overseas. VSO will not cover the cost of eny long term definitive, restorative dental treatment (see attached information for further details). {tis the volunteer's responsibility to cover any costs related to this examination and to ensure that the completed form is returned to the VSO Medical Unit, 100 London Road, Kingston upon Thames KT2 6QJ Patient and dentist details Patient’s name and address: OLORUNYOM OLAWALE 19. OLOWOLOGBON STREET AKOWONJO, LAGOS, NIGERIA Date of birth: 24/04/1976 Date of examination: 23 [o%/2017 Dentist’sname and address: Na MNB-GAOGO SLuteunce BEE Hess teser7AL, ISS Alcomengo eb A RObKENYO LK AGo.S- Telephone andfaxx O56 DS spAues p RIGHT Somalia if | | EEE tt [24 | 22 | 25! 26| 25 | 26 27 | 28 4i | 31 32] 33/38] 3637 | 38 ME fi ie Lay Hola’ [J siering © Grown RET Root Fiting decay FF} ico Beni D barre ea egenk Geegetscnion _ Faison snr 0 fe foe God. Mae < Seeelan ie oe ioe {Starticant bone joss| ea [Seer {ey poor ‘Oeclusadtincisat CPN toothware iy (Setous Relevant dental history |n view of the information provided we would be eratetul it vou could supply us with the Toviowing detaus: [Are there any restorations or hard surfaces under review that you feel will require any treatment within the next two years? If YES, please give details below: /Are there any radiographic findings which you feel do not need attention at present but that 'you would wish to keep under review if the patient was remaining in the UK? (Please take into account the fact that the volunteer may not have access to dental treatment during their placement), ves) IF YES, please give details below: | Ll Are wisdom teeth or any other unerupted teeth present? YES/NO) 1f YES, please give details below: Is there any past history of trauma which is the subject of continuing review? vyes/(> IFYES, please give details below (Including details of review programme now in place): ‘What is the patient’s current periodontal status? Please indicate below: THE PE RK0O rw y~7TAL STAI — NAO Pre-departure dental treatment required ‘As VoU will not be able to auarantee tne accessibiiny oF auaity oF the dental raciities in the volunteer's country of placement It is essential thal all necessary work is carried out before the volunteer goes overseas. [does the patient require any treatment before their departure? YES /—(0) IFYES, please give details below: Has the required treatment indicated above been carried out? YES/NO Please give date treatment was completed and any adcitional observations at the time of. treatment: Is the required treatment in progress? ‘YES/NO | lease date when treatment s due to be completed? [Following this examination and the information provided regarding VSO placements do you ‘consider this person dentally fit to work overseas with VSO? ‘ral hygiene and dental care overseas [As sixemonthly check-ups, scaling and polishing will not be available during the volunteer's service, what advice have you given the patient on appropriate orat hygiene and dental care [whilst overseas? Please give details below: OW AL HALE TT (AaTene so Liké bruckine Tce DALLT WM ® FLyst ee PASTE! METACY AOWCE St M7 TPG erip

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