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1-2 A 1-2 B 3-4 B 3-4 C 5-6 C 5-6 D 7-8 D 7-8 E 9-10 E 9-10 F 11-12 F 11-12 G 13-14 G 13-14 H 15-16 H 15-16 I 17-18 I 17-18 J 19-20 J 19-20 K None Noted Presence of Intraoral Soft Tissue Pathology? Y Please check any or all that apply: N If yes, check all that apply A B C D Ulcer Mucocele Inflamed gingiva Other 2 Black not Hispanic 3 Hispanic 4 Am. Indian/Alask. Native A Early Tooth.

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