source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWDO1.m@ 628

DVBCWDO1 ;ALB/CMM DENTAL AND ORAL WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;Narrative:  Regional Office action is required for all dental treatment
 ;;based on combat wounds, service trauma, prisoner of war or extracted 
 ;;teeth under 38 CFR 17.123.
 ;;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe:
 ;;    1.  Describe extent of functional impairment due to loss of motion
 ;;        and masticatory function loss.
 ;;
 ;;
 ;;    2.  Describe the extent and number of missing teeth and whether 
 ;;        the masticatory surface can be replaced by a prosthesis.
 ;;
 ;;
 ;;    3.  If limitation of inter-incisal range of motion, provide actual
 ;;        range in mm (i.e., 0-Xmm) and also provide lateral excursion 
 ;;        (i.e., 0-Xmm).
 ;;
 ;;
 ;;    4.  Describe the extent of any bone loss of mandible, maxilla, or
 ;;        hard palate.  For hard palate and maxilla bone loss, state 
 ;;        whether replaceable by prosthesis.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Provide:
 ;;    1.  X-ray to determine extent of bone tissue loss.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;TOF
 ;;E.  Diagnosis:
 ;;
 ;;    1.  Give etiology where there is loss of teeth due to loss of 
 ;;        substance of body of maxilla or mandible.
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END