Mucosal Examination Chart
®
Patient name: Case Number:
www.velscope.com
Exam Date: Clinician:
LIP
Form A - Upper/Lower Arch
13
12
11
21
22
23 24
14
25
15
26
16
27
17
28
18
LEFT
RIGHT
38
48
37
47
36
46
35
45
34
44 43
33 42
41 31
32
LIP
Clinical Impression:_________________________________________________________________________ © 2007 LED Dental Inc.
01-08-07
®
Mucosal Examination Chart Patient name: Case Number: Exam Date: Clinician:
www.velscope.com
Form B: Tongue-Lateral View
LEFT RIGHT 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Form C: Tongue Underside
LEFT
RIGHT
38
48
37
47
36
46
35
45 44
43
42
41 31
32
34 33
LIP
Clinical Impression:_________________________________________________________________________ © 2007 LED Dental Inc.
01-08-07