31 30 28 28 27 2825 24 23 22 21 20 19 16 17 re Ir Oral Hygiene: Good Fair / oor CPITN: 3 3 2- 9 Head & Nock / Soft natio: 1C7 t 1 F: Clessilficatiom CLT Pain Scale: /10 Dental Prostheses at Intake: Yes 0 Type: Age: Cannon: rColmreoll rtu ssicy, la -)e--r r'" " i j We:JM In i '