Mouth, Lips, and Tongue

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Disfigurement - if present, order color photographs.
2. Interference with mastication.
3. Interference with speech - state extent.
4. Absence of all or part of tongue - describe.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: