牙科检查报告DENTAL EXAMINATION REPORT.PDF

牙科檢查報告 DENTAL EXAMINATION REPORT (必須由註冊牙醫填寫，有關費用由受保人負責) (To be completed by Registered Dentist at Person to be insured’s expense) 本表格只適用於牙科保障及每位受保人必須填寫。This form is applicable to Dental Benefits only and should be filled in for each person to be insured. 如需更多表格填寫，請自行影印。Should you need additional forms, photocopies are acceptable. 請在適當的空格內填上 Please tick the boxes where appropriate . 受保人資料DETAILS OF THE PERSON TO BE INSURED 受保人姓名(英文正楷) Name of Person to be Insured (English Block Letter) 年齡Age 性別Sex  男 Male  女 Female 香港身份證號碼HKID Card No 醫療問卷MEDICAL QUESTIONNAIRE 1 這次檢查中有否拍攝牙科X 光作檢查？ 有Yes  否No  Have any dental x-rays been taken during this examination? 若 「有」，請描述X 光性質及拍攝原因 If Yes, please describe nature of x-rays and reason for taking 2 請描述受保人的假牙狀況(若適用)及你認為受保人的假牙狀況是否保持良好及受保人是否正確護理自己的假牙？ Please describe general condition of dentures (if any) and do you think the person to be Insured’s denture is in good condition and well taken care of? 3 就受保人現時的牙齒狀態 ，是否出現口腔內顎骨結構異常(包括先天性、遺傳性或後天意外所引致)一般代謝性病 是Yes  否No  變、發炎性病變及內分泌病變等 ，而此等病變會對受保人的牙齒構成已知的損害？ Is there any pre-existing pathology which could cause a worsening of the person to be insured’s dentition are included as pre-existing pathologies the maxilla deformation (congenital, hereditary or accidental) and also but not limited to all general metabolic, infections and endocrine pathologies having an incidence on dental status? 若 「是」，請詳述 If Yes, please give details below 4 現時是否有徵狀顯示牙肉有問題 ，包括已顯示或未曾顯示在牙齒的健康上？