MARK ALL EXISTING RESTORATIONS AND MISSING TEETH ON THIS CHART Estimated Age Sex Race Circle descriptive term Prosthetic appliances present Maxilla Full denture Partial denture LEFT RIGHT Fixed bridge Mandible Full denture Partial denture Fixed bridge Describe completely all prosthetic appliances or fixed bridges Stains on teeth Slight Moderate Severe MARK ALL CARIES ON THIS CHART Circle descriptive term Outline all caries and “X” out all missing teeth Relationship Normal Undershot Overbite Periodontal Condition Excellent Average LEFT RIGHT Poor Calculus Slight Moderate Severe 72