kertas screening

Nama: Jenis Kelamin/Usia: Alamat: Telepon: Keluhan: Kondisi gigi geligi: 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 VI V IV II I II I I II II I IV V VI VI V IV II I II I I II II I IV V VI 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

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Nama:Jenis Kelamin/Usia:Alamat:

Telepon:Keluhan:

Kondisi gigi geligi:

8765432112345678

VIVIVIIIIIIIIIIIIIVVVI

8765432112345678

Diagnosis:

Nama:Jenis Kelamin/Usia:Alamat:

Telepon:Keluhan:

Kondisi gigi geligi:

8765432112345678

VIVIVIIIIIIIIIIIIIVVVI

8765432112345678

Diagnosis:

Dr.irwin Screening

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