Respondent sequence number
Overall Oral Health Exam Status
Referral Status Code
Must always take antibiotics?
Had a heart problem?
Had congenital heart murmurs?
Had heart valve problem?
Had congenital heart disease?
Had bacterial endocarditis?
Had rheumatic fever?
Have kidney disease w/ renal dialysis?
Have other artificial material?
Have a hip, bone, or joint replacement?
Describe the cond. of your mouth/teeth
Toothache
Sensitivity
Cavities/Caries
Broken/missing fillings or restorations
Broken / fractured teeth
Staining/discoloration of teeth
Crooked teeth or need braces
Teeth needing extractions
Missing teeth
Denture problems
Periodontal problems
Unsatisfactory prior dental experience
None/no specific problem
Other
Removable complete/partial max denture
Wears complete/partial max denture
Removable complete/partial mand. denture
Wears complete/partial Mand. denture
Overall recommendation for care
Untreated Caries / Restorative needs
Periodontal needs
Gingival / OHI needs
Assessment of soft tissue lesion
Denture/Partial Denture/plates
Some other finding
No significant needs
Other Referral Comments
Was participant exam position recumbent