Pre-Sea Dental Examination Form
Personal Information
Name
Rank
Date of Birth
Nationality
Identification No.
Date of Examination
Medical History
Any history of dental treatment/surgery?
Allergies (if any)
Dental Examination
Tooth
Normal
Caries
Missing
Filled
Remarks
Upper Right
Upper Left
Lower Right
Lower Left
Gums Condition
Oral Hygiene
Other findings
Fit for Sea Service
Fit for Sea Service:
Fit
Unfit
Dentist Name
Signature
Date