Dd Form 2813 – Fill Out and Use This PDF

The public report ing burden f or t his collect ion of inf ormat ion is est imat ed t o average 3 minut es per response, including t he t ime f or review ing inst ruct ions, searching exist ing dat a sources, gat hering and maint aining t he dat a needed, and complet ing and review ing t he collect ion of inf ormat ion. Send comment s regarding t his burden est imat e or any ot her aspect of t his collect ion of inf ormat ion, including suggest ions f or reducing t he burden, t o Depart ment of Def ense, Washingt on Headquart ers Services, Direct orat e f or Inf ormat ion Operat ions and Report s (0720-0022), 1215 Jef f erson Davis Highw ay, Suit e 1204, Arlingt on, VA 22202-4302. Respondent s should be aw are t hat not w it hst anding any ot her provision of law , no person shall be subject t o any penalt y f or f ailing t o comply w it h a collect ion of inf ormat ion if it does not display a current ly valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.

PRIVACY ACT STATEM ENT

	AUTHORITY: Public Law 105 -85, Sec. 765; DoD Direct ive	ROUTINE USE(S): None.
	6490 .2; E.O. 9397 .
	PRINCIPAL PURPOSE(S): An assessment by a dent ist of t he	DISCLOSURE: Volunt ary; how ever, f ailure t o provide t he
		inf ormat ion may result in delays in assessing your dent al
	st at e of your dent al healt h f or t he next 12 mont hs is needed
		healt h needs f or milit ary service.
	t o det ermine your f it ness f or prolonged dut y w it hout ready
	access t o dent al care.

6 . EXAM INATION RESULTS Dear Doct or,

The individual you are examining is a Guard/Reserve member of t he Unit ed St at es Armed Forces. This member needs your assessment of his/her dent al healt h f or w orldw ide dut y. Please mark (X) the block t hat best describes t he condit ion of t he member, using as a suggest ed minimum a clinical examinat ion w it h mirror and probe, and bit e w ing radiographs. This form is meant to determine fitness for prolonged duty w ithout ready access to dental care and is not intended to address the member' s comprehensive dental needs.

(1)Pat ient has good oral healt h and is not expect ed t o require dent al t reat ment or reevaluat ion f or 12 mont hs.

(2)Pat ient has some oral condit ions, but you do not expect t hese condit ions t o result in dent al emergencies w it hin 12 mont hs if not t reat ed (i.e., requires prophylaxis, asympt omat ic caries w it h minimal ext ension int o dent in, edent ulous areas not requiring immediat e prost het ic t reat ment ).

(3)Pat ient has oral condit ions t hat you do expect t o result in dent al emergencies w it hin 12 mont hs if not t reat ed. Examples of such condit ions are: (X t he applicable block or specif y in t he space provided)

(a)Infections: Acut e oral inf ect ions, pulpal or periapical pat hology, chronic oral inf ect ions, or ot her pat hologic lesions and lesions requiring biopsy or aw ait ing biopsy report .

(b)Caries/Restorations: Dent al caries or f ract ures w it h moderat e or advanced ext ension int o dent in; def ect ive rest orat ions or t emporary rest orat ions t hat pat ient s cannot maint ain f or 12 mont hs.

(c)M issing Teeth: Edent ulous areas requiring immediat e prost hodont ic t reat ment f or adequat e mast icat ion, communicat ion, or accept able est het ics.

(d)Periodontal Conditions: Acut e gingivit is or pericoronit is, act ive moderat e t o advanced periodont it is, periodont al abscess, progressive mucogingival condit ion, moderat e t o heavy subgingival calculus, or periodont al manif est at ions of syst emic disease or hormonal dist urbances.

(e) Oral Surgery: Unerupt ed, part ially erupt ed, or malposed t eet h w it h hist orical, clinical, or radiographic signs or sympt oms of pat hosis t hat are recommended f or removal.

(f ) Other: Temporomandibular disorders or myof ascial pain dysf unct ion requiring act ive t reat ment .

(4)If you select ed Block (3) above, please circle t he condit ion(s) you ident if ied in t his pat ient if t hey appear above, or brief ly describe t he condit ion(s) below :

(5) Were X-rays consult ed?		YES		NO	IF YES, DATE X -RAY WAS TAKEN (YYYYMMDD)
7 . DENTIST' S NAM E (Last , First , Middle Init ial)					8 . DENTIST' S ADDRESS (Include ZIP Code)
9 . DENTIST' S TELEPHONE NUM BER (Include Area Code)

DD FORM 2 8 1 3 , DEC 1 9 9 9